If you choose to proceed with an appointment with Dr. Choll Kim, we will ask for a non-refundable one-time payment of the below applicable charges due at the time of your appointment.
Please initial each paragraph as you read it, provided that you agree with the statement contained therein.
1. I, the Medicare beneficiary, or my legal representative understand that Dr. Choll Kim has not been excluded from Medicare under sections 1128, 1156, or 1892 of the Social Security Act. Dr. Choll Kim's NPI: 1124043765.
2. I, the Medicare beneficiary, or my legal representative accept full responsibility for payment of charges for all office visit services furnished by Dr. Choll Kim, as stated above.
3. I, the Medicare beneficiary, or my legal representative understand that Medicare limits do not apply to what Dr. Choll Kim may charge for items or services furnished.
4. I, the Medicare beneficiary, or my legal representative agree not to submit a claim to Medicare or to ask Dr. Choll Kim to submit a claim to Medicare.
5. I, the Medicare beneficiary, or my legal representative understand that Medicare payment will not be made for any items or services furnished by Dr. Choll Kim that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
6. I, the Medicare beneficiary, or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and I am 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.
7. I, the Medicare beneficiary, or my legal representative understand that the expected or known effective date of the opt-out period for Dr. Choll Kim is May 1, 2023 (effective date) and automatically renews every 2 years.
8. I, the Medicare beneficiary, or my legal representative understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
Phone: (619) 344-6918 | Fax: (619) 333-6029 Website: www.excelspine.com Address: 6719 Alvarado Road, Suite 304 San Diego, CA 92120