Common Contracts
1 similar Medicare Opt Out Agreement contracts
MEDICARE OPT OUT AGREEMENTMedicare Opt Out Agreement • August 12th, 2020
This agreement is between Dr. Robert Reiser ("Provider"), whose principal place of business is 1036 Sir Francis Drake Blvd, Suite 13, Kentfield, CA 94904 and patient ________________ ("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 Provider has informed Patient that Provider has opted out of the Medicare program effective on _____/_____/_____ 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.
