This document is required for patients with an active Medicare account seeking care from a physician who has opted out of Medicare.
Provider Opt-Out Status
- I understand that my Medicare program will neither cover nor pay for any services I receive from Nelson X. Simmons, MD, or Jill Arnold, P.A. (Herinafter "Personal M.D. Provider.")
- I understand that the Personal MD Providers have opted out of the Medicare program under Section 1802 (b) of the Social Security Act.
- I understand that Personal MD Providers have not been banned or excluded from participating in Medicare, and this decision to opt out of receiving payment from Medicare is voluntary.
Patient Agreement
- I agree not to bill the Medicare Program ("Medicare") for any service I receive from my Personal MD Provider, nor will I ask my Personal MD Provider to bill Medicare for me.
- I hereby accept full responsibility and acknowledge and agree that I am personally responsible for any charges not covered by Medicare or any additional insurance coverage.
- I agree to pay any charges I incur when I seek care from my Personal MD Provider. My Personal MD Provider will determine the fee amount and will not otherwise be limited by Medicare.
- I understand Medigap or other supplemental healthcare plans will not pay any part of the fees charged by my Personal MD Provider.
- I understand that there are physicians other than my Personal MD Provider who will accept my Medicare coverage and payment. I also understand I have the right to receive care from another physician who will accept Medicare coverage and payment. I am not required to enter this private contract with my Personal MD Provider.
- I understand that entering this private contract does not keep me from seeking care from a Medicare provider, including a specialist, at any time for any reason.