Medicare Opt Out AgreementMedicare Opt Out Agreement • January 28th, 2023
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
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 ,
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.
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
Medicare Opt Out AgreementMedicare Opt Out Agreement • February 9th, 2021
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 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”).
