This agreement is between Serina Lewis, MD (“Physician”), practicing at location 757 Frederick Rd, Suite 204, Catonsville, MD 21228, and (Patient) who resides at and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. Serina Lewis, MD has informed Patient that Physician has opted out of the Medicare program effective on 8/1/2024 and is excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.
I understand and hereby choose to opt out of the Medicare program for all services I furnish. I understand that by opting out, I will not be able to bill Medicare or receive Medicare reimbursement for services provided to Medicare beneficiaries.
Patient acknowledges that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Physician’s Fee Schedule.
Patient is not currently in an emergency or urgent health care situation.
Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
Patient acknowledges that a copy of this contract has been made available to him/her.