This is the Form the Government Requires Medicare Patients to Fill Out and Sign for Services Provided by Dr. Huntoon

  Medicare Opt Out Contract

“This agreement  is between  Dr. Lawrence  Huntoon  (“Physician”),  whose  principal place of business   is   Chapel   Park   Villa,  7008   Erie   Rd.,   Suite  #6,   Derby,   NY   14047,   and patient _______________

(“Patient”),                who                resides               at _________________________________________

beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997.  The Physician has informed Patient that Physician has opted out of the Medicare program effective on 02/15/2004 (updated 02/15/2014) for a period of at least  two  years,  and is not  excluded  from participating  in  Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.


Physician  agrees  to  provide  the  following  medical  services  to  Patient  (the “Services): Consultation, office  visits,  canalith repositioning maneuver (CRP).

In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the physician fee schedule (posted at  and available by request by  phone  or  in  person  in  the office).   Patient  also  agrees,  understands  and  expressly acknowledges the following:     [ask Patient to initial each one below:]

              Patient agrees not to submit a claim (or request that Physician submit a claim) to the

Medicare program with respect to the Services, even if covered by Medicare part B.


              Patient is not currently in an emergency or urgent health care situation.


              Patient acknowledges  that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.


            Patient   acknowledges    that   Medi-Gap    plans    will    not    provide    payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.


            Patient  acknowledges  that  he  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  understands  that  Medicare  payment  will  not  be  made  for  any items or services  furnished by the Physician that would have otherwise been covered by Medicare if  

there were no private contract and a proper Medicare claim were  submitted.


              Patient acknowledges that a copy of this contract has been made available to him.



               Patient  agrees  to  reimburse  Physician  for  any  costs  and reasonable attorney’s fees that result from violation of this Agreement by Patient or his beneficiaries

Executed on                                         (Date)


by                                                                                (Patient Name)and

Lawrence R. Huntoon, M.D., Ph.D., F.A.A.N.  (Physician Name)



[Patient Signature]




[Physician Signature]