Terms of Agreement
Dr. Stryker does not accept insurance and is not in network with any insurance company. We ask for a copy of your insurance card to submit to the facility in to order labs, imaging and medications.
I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay JEANNE N. STRYKER M.D., as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided.
I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, procedures and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under.
I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same.
I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action to obtain (or protect) benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan.
This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.
Medicare Private Contract
ALL PATIENTS MUST SIGN :
Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary. Signatures from the provider, a witness and the/ beneficiary or their legal representative are required below. The supplier must submit an affidavit to Medicare expressing his / her decision to opt out.
I, Jeanne N. Stryker, MD., have not been excluded from Medicare under sections 1128, 1156, or 1892 of the Social Security Act. NPI 1144251596.
I, (the Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services furnished by Jeanne N. Stryker, MD.
I, (the Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to Jeanne N. Stryker, MD may charge for items or services furnished.
I, (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Jeanne N. Stryker MD to submit a claim to Medicare.
I, (the Medicare Beneficiary) or my legal representative understand that Medicare payment will not be made for any items or services furnished by Jeanne N. Stryker, MD that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
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.
The effective date of the opt out is:October 1, 2024 which automatically renews every two years.
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. Supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
I, (the Medicare Beneficiary) or my legal representative will receive or have received a (A photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract.
This contract cannot be entered into by me, (the Medicare beneficiary), or my legal representative during a time when I, (the Medicare beneficiary), require emergency care services or urgent care services. (HOWEVER, a physician / practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance 3044.28 of the Medicare Carrier's Manual).
I, Jeanne N. Stryker, M. D., will retain the original contract (original signatures of both parties required) for the duration of entire time.