OUT AGREEMENT. To Be Completed by Clients 62 Years Old and Older This agreement is between Xxxxxxxxx X. Xxxxx, LCSW-C [Clinician], whose principal place of business is 0000 Xxxx Xxxx Xxxxxxx, Xxxxx 000, Xxxxxxxx, XX and ["Patient"], who resides at and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Clinician has informed Patient that Clinician has opted out of the Medicare program effective on 7/30/09 and expects to remain always on “opt out” status in the future, 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. Clinician agrees to provide the following medical services to Patient (the "Services"): • Psychotherapy Consultation and Evaluation • Individual Psychotherapy In exchange for the Services, the Patient agrees to make payments to Practitioner pursuant to the Fee Schedule detailed in the Client-Clinician Agreement Form provided to the Patient by the Clinician. Patient also agrees, understands and expressly acknowledges the following: • Patient agrees not to submit a claim (or to request that Clinician 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 Clinicians 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 Clinicians 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 Clinician 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 Clinician th...
OUT AGREEMENT. Xxxxxx agrees and understands the following:
OUT AGREEMENT. Tenant agrees and understands the following:
OUT AGREEMENT. This Agreement applies only to the shares cited in paragraphs 6a, 6b, and 6c of the attached "Settlement Agreement". Phoenix, Metz xx their assigns hereby agree to restrict their sale(s) of LEEP stock, which is subject to this Agreement, to 5% of their total position per quarter. Phoenix, Metz xx their assigns understands this right is not cumulative, i.e., if the full 5% permitted to be sold is not sold in a given quarter, the seller can not accumulate and carry over the unsold portion to add to another 5% increment for sale in a subsequent period. Phoenix, Metz xx their assigns hereby agree to advise LEEP's management each time they wish to sell stock which is subject to this Agreement and to give LEEP a 10 day window of opportunity to supply a buyer for increment (s) they wish to sell. After the 10 day period, if LEEP has not supplied a buyer or buyers, then Phoenix, Metz xx their assigns shall have the right to sell the subject increment of stock in the US market. Phoenix, Metz xx their assigns agree not to sell any shares into the US market at a price less than $0.03 higher than the bid price on the day(s) the stock is sold.
OUT AGREEMENT. (if applicable) The Interconnecting Customer, after conducting its own due diligence and having read and understood this Agreement, elects to opt-out of participating in the Group and assumes all risk in making such election. Interconnecting Customer: By: Date Name: Its: Attachment 1 Explanation of Potential Risks and Benefits of Opting-Out of Group Participation [TO BE COMPLETED BY COMPANY]
OUT AGREEMENT. The principal terms of the Fitting-out Agreement are set out below: Date 26 August 2021 Parties
