Agreement By Medicare Beneficiary For Medical Services
Date: _________ Time: __________
__________________________________, a patient and Medicare Part Beneficiary (“Patient”), and David Perlmutter, M.D., P.A., a physician licensed to practice medicine in Florida (“Physician”), enter into this agreement for the provision of medical services specified herein (“Services”) in accordance with the provisions of Section 4507 of the Balanced Budget Act of 1997. Wherefore, in exchange for consideration, the receipt and sufficiency of which the Parties hereby acknowledge, Patient and Physician agree as follows:
1. Patient acknowledges and agrees that this Agreement has been entered into, and that Patient has received a copy of this Agreement, before Physician has provided the services specified herein to Patient.
2. Patient acknowledges and agrees that this Agreement has not been entered into at a time when Patient is facing an emergency or urgent health care situation.
3. The services to be provided to 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 Physician submit a claim on Patient’s behalf) under the Social Security Act, as amended (42 U.S.C. § 1395a), for the Services, even if such Services are otherwise covered under Medicare Part B.
5. Patient agrees 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 the right to have the Services provided by other physicians or practitioners who have not opted-out of Medicare and for whom payment would be made under Medicare, 42 U.S.C. § 1395a. Patient acknowledges that he or she 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.
9. Physician has informed Patient that Physician is not excluded from participating in Medicare Part B under 42U.S.C. § 1128, 1156, or 1892 or any other section of the Social Security Act.
10. By signing this contract Patient understands that Medicare payment will not be made for any items or services furnished by the physician or practitioner that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.
11. Physician filed an affidavit with Medicare effective on April 1, 2004. That affidavit expires on April 1, 2006. This Agreement expires on April 1, 2006.
Signature of Patient:_______________________ Date:________ Witness:________________
Signature of Physician:_____________________Date:________ Witness:_________________
