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 www.PrivateNeurology.com 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)