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Agreement By Medicare Beneficiary For Medical Services

Date: _________ Time: __________

__________________________________, a patient and Medicare Part Bbeneficiary (“Patient”), and David Perlmutter, M.D., P.A., aphysician licensed to practice medicine in Florida (“Physician”), enter into this agreement for the provisionof medical services specified herein (“Services”) inaccordance with the provisions of Section 4507 of the Balanced BudgetAct of 1997. Wherefore, in exchange for consideration, the receipt andsufficiency of which the Parties hereby acknowledge, Patient andPhysician agree as follows:

1. Patient acknowledges and agreesthat this Agreement has been entered into, and that Patient has receiveda copy of this Agreement, before Physician has provided the servicesspecified herein to Patient.
2. Patient acknowledges and agreesthat this Agreement has not been entered into at a time when Patient isfacing an emergency or urgent health care situation.
3. Theservices to be provided Patient are: medical and physician services,ancillary health services, diagnostic testing, and office visits(collectively referred to hereinafter as "Services").
4. Patient agrees not to submit a claim (or request that Physiciansubmit a claim on Patient’s behalf) under the Social Security Act,as amended (42 U.S.C. § 1395a), for the Services, even if suchServices are otherwise covered under Medicare Part B.
5. Patientagrees to be personally responsible, whether through private insuranceor otherwise, for the payment of Services.
6. Patientacknowledges that Medicare will not provide reimbursement for theServices and that no Medicare fee limits (including those specified in42 U.S.C. §§ 1395a; 1848(g)) will apply to the amountPhysician charges for Services.
7. Patient acknowledges thatMedigap plans under 42 U.S.C. § 1882 do not, and other supplementalinsurance plans may not, make payments for the Services.
8. Patient acknowledges that, as a Medicare beneficiary, Patient has theright to have the Services provided by other physicians or practitionerswho have not opted-out of Medicare and for whom payment would be madeunder Medicare, 42 U.S.C. § 1395a. Patient acknowledges that he orshe is not compelled to enter into private contracts that apply to otherMedicare-covered services furnished by other physicians or practitionerswho have not opted-out.
9. Physician has informed Patient thatPhysician is not excluded from participating in Medicare Part B under 42U.S.C. § 1128, 1156, or 1892 or any other section of the SocialSecurity Act.
10. By signing this contract Patient understandsthat Medicare payment will not be made for any items or servicesfurnished by the physician or practitioner that would have otherwisebeen covered by Medicare if there were no private contract and a properMedicare claim had been submitted.
11. Physician filed anaffidavit with Medicare effective on April 1, 2004. That affidavitexpires on April 1, 2006. This Agreement expires on April 1, 2006.

Signature of Patient:_______________________ Date:________ Witness:________________

Signature of Physician:_____________________Date:________ Witness:_________________