MEDICARE PRIVATE CONTRACT

Provider: Brandy Chappell ARNP and Bloom Health Care, LLC

Patient:

Effective Date:

This contract is between Brandy Chappell ARNP and Bloom Health Care LLC and the signer of this document.                                

("Beneficiary"). The Beneficiary is a Medicare Part B enrollee, and the Provider has opted out of the Medicare program.

1. Acknowledgments by the Beneficiary

By signing this contract, the Beneficiary (or their legal representative) understands and agrees to the following:

Full Financial Responsibility: I agree to pay the Provider’s fees in full at the time of service. I understand that no Medicare payment (either direct or indirect) will be made for services provided by this Provider.
No Claims to Medicare: I agree not to submit a claim to Medicare or ask the Provider to submit a claim to Medicare, even if the service would otherwise be covered.
No Medicare Price Limits: I understand that Medicare "limiting charges" (the caps on what a doctor can charge) do not apply to this Provider.
Medigap Limitations: I acknowledge that supplemental (Medigap) insurance and other private insurers will likely not pay for services provided under this contract.
Right to Other Providers: I understand that I have the right to receive medical services from other physicians or practitioners who have not opted out of Medicare.
Not an Emergency: I certify that I am not currently experiencing a medical emergency or in need of urgent care as I sign this contract.
2. Provider Disclosures

The Provider is not currently excluded from participating in Medicare under Sections 1128, 1156, or 1892 of the Social Security Act.
The Provider will provide the Beneficiary with a copy of this contract before any services are rendered. You may directly print it out.
This contract remains in effect for the duration of the Provider’s current two-year opt-out period and must be renewed every two years.
3. Acceptance of Terms

By signing below, both parties agree to the terms above. This agreement shall remain on file in the Provider's office for at least two years.