Medicare Opt Out AgreementMedicare Opt Out Agreement • November 7th, 2020
This agreement (“Agreement”) is entered into by and between Rhode Island Dermatology, Inc., a Rhode Island professional corporation, owned and operated by Caroline A. Chang, MD, (the “Physician”), whose principal medical office is located at 5586 Post Road, Suite 6, East Greenwich, RI 02818 and
PRIVATE CONTRACT – Medicare opt out April 1, 2020 - 2022Medicare Opt-Out Agreement • April 4th, 2020
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 Physician has informed Patient that Physician has opted out of the Medicare program effective on April 2020 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.
PRIVATE CONTRACT – Medicare opt out April 1, 2022 - 2024Medicare Opt-Out Agreement • March 24th, 2022
This agreement is between Dr. Adrian J. Hohenwarter ("Physician"), whose principal place of business is 745 S. Grant Street Palmyra, PA 17078, and patient 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 Physician has informed Patient that Physician has opted out of the Medicare program effective on April 2022 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.
Medicare Opt-out agreementMedicare Opt-Out Agreement • June 8th, 2017
This agreement (“Agreement”) is entered into by and between Blue Skies Family Medicine, a North Carolina professional corporation owned and operated by Katherine Weeks M.D. (“Physician”), whose principal medical office is located at 363 Williamson Road, Suite 103, Mooresville, NC 28117 and , a beneficiary enrolled in Medicare Part B (“Beneficiary”), who resides at _
Medicare Opt Out AgreementMedicare Opt Out Agreement • October 15th, 2015
This agreement (“Agreement”) is entered into by and between Empower Family Medicine, LLC, a Georgia professional corporation, owned and operated by Dr. Melissa Black, MD, (the “Physician”), whose principal medical office is located at 209A Swanton Way Suite 101 Decatur, GA 30030, and ,
Heather Stone, Ph.D., PSY 21112 www.drheatherstone.comMedicare Opt-Out Agreement • May 2nd, 2023
Appendix 2 Medicare Opt Out AgreementMedicare Opt Out Agreement • February 3rd, 2021
This contract is entered into, by and between Jan Hester MD PC (herein after called the “Physician”), whose principal medical office is located at 1120 E Elizabeth St, Building G, Suite 1 Fort Collins CO 80524 and (hereinafter called the “Beneficiary”), who resides at
Appendix 2Medicare Opt Out Agreement • July 14th, 2014
This agreement (“ Agreement” ) is entered into by and between AtlasM D Concierge Family Practice, LLC, a Kansas professional corporation, owned and operated by Dr Josh Umbehr & Dr Doug Nunamaker, MD, (the “ Physician” ), whose principal medical office is located at 10500 E. Berkeley Square Parkway Suite 200, Wichita Kansas, and
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.
ContractMedicare Opt Out Agreement • November 19th, 2016
Heather Stone, Ph.D., PSY 21112 www.drheatherstone.comMedicare Opt-Out Agreement • May 11th, 2023
Medicare Opt Out AgreementMedicare Opt Out Agreement • July 14th, 2014
This agreement (“ Agreement”) is entered into by and between Stahl Primary Care, LLC, a Georgia professional corporation, owned and operated by Dr Stahl, (the “Physician ”), whose principal medical office is located at 5925 Iron Gate Trace, Cumming, GA 30040, and
Appendix 2 Medicare Opt Out AgreementMedicare Opt Out Agreement • March 18th, 2018
This agreement (“Agreement”) is entered into by and between BloomMed, LLC, a Texas professional corporation, owned and operated by Stephanie L. Cudjoe, MD (the “Physician”), whose principal medical office is located at 4510 Medical Center Drive, #303, McKinney, TX 75069 and
Medicare Opt-Out AgreementMedicare Opt-Out Agreement • July 23rd, 2024
This agreement is between Elite Primary Care & Wellness, whose principal place of business is 727 Mt. Tabor Rd, New Albany, IN 47150 and
Complete the following form if you have Medicare:Medicare Opt-Out Agreement • January 30th, 2022
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. Dr. Lisa Mainier has informed Beneficiary or his/her legal representative that she has opted out of the Medicare program effective on July 1, 2016 for a period of at least two years. Dr. Mainier is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
Appendix 2 Medicare Opt Out AgreementMedicare Opt Out Agreement • June 1st, 2020
This agreement (“Agreement”) is entered into by and between Quick Medical Clinic, LLC, a Washington State professional corporation, owned and operated by Dr. Paul Williams, MD and the physicians providing the services, Dr. Lisa Neff, DO, Dr. Paul Williams, MD, and Dr. Eric DeMun, MD, (the “Physician”), whose principal medical office is located at 2526 Colonial Dr., Centralia Washington, and the beneficiary who resides in Washington State.
MyMD Direct, PLLCMedicare Opt-Out Agreement • April 15th, 2020 • North Carolina
Medicare Opt Out AgreementMedicare Opt Out Agreement • December 14th, 2022
This agreement (“Agreement”) is entered into by and between Cannon Dermatology LLC, a Maryland limited liability corporation, owned and operated by Sarah C. Cannon, MD (the “Physician”), whose principal medical office is located at 2012 S. Tollgate Road, Suite 206, Bel Air, MD 21015 and
Medicare Opt Out Agreement for MD, NPMedicare Opt Out Agreement • June 4th, 2021
- Patient 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 the provider has opted out of the Medicare program effective from
Medicare Opt-Out AgreementMedicare Opt-Out Agreement • November 17th, 2021
This agreement (“Agreement”) is entered into and by Caitlin Prickett, DO and Associates, PLLC d/b/a Concierge Medicine of Boca Raton, as a Ms.Medicine Affiliate and a Medical Practice owned and operated by Caitlin Prickett, DO (the “Physician”), whose principal medical office is located at 825 Meadows Road Suite 111, Boca Raton Florida 33486 and a beneficiary enrolled in Medicare Part B (“Beneficiary”).
Green Oaks Medical Center, PC Dr. Christine GreenMedicare Opt-Out Agreement • June 27th, 2019
This agreement is between Dr. Green (“Physician”), whose principal place of business is Green Oaks Medical Center, PC (address above) and patient who resides at
Medicare Opt Out AgreementMedicare Opt Out Agreement • September 5th, 2018
This agreement (“Agreement”) is entered into by and between New South Family Medicine, LLC, a South Carolina professional corporation, owned and operated by Dr. Jessica Kaiser Mendelsohn (the “Physician”), whose principal medical office is located at 1365 Broadcloth Street, Suite 203 Fort Mill, SC 29715 and
Medicare Opt Out Agreement for MD, NP (Hall & Lambour)Medicare Opt Out Agreement • April 11th, 2021
20176 and the patient: __ _ ("Patient"). Patient 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 the provider has opted out of the Medicare program effective from 12/ 02/2017 to 12/02/2019, 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.
Vital Roots Natural Medicine PLLC 188 Charlotte StreetMedicare Opt Out Agreement • September 17th, 2020
This agreement is between Malinda Achard PA-C whose place of business is Vital Roots Natural Medicine PLLC 68 Orange Street Asheville, NC 28801, and Beneficiary:
