Medicare Private ContractMedicare Private Contract • April 5th, 2022
A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to charge a patient more than a certain percentage in excess of the Medicare fee schedule amount. A new provision, which became effective on January 1, 1998, permits physicians and patients to enter into private arrangements through a written contract under which the patient may agree to pay the physician more than that which would be paid under the Medicare program.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • October 28th, 2021
CATALINA ARBOLEDA, PH.D. LICENSED PSYCHOLOGIST 617-876-6535Medicare Private Contract • September 2nd, 2020
This agreement is between Dr. Catalina Arboleda, a Licensed Psychologist, (hereinafter called the "Physician"), whose principal place of business is at 256 Concord Avenue, Cambridge, MA 02138, and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • April 9th, 2020
This agreement is entered into by and between Joseph T. Andrews, M.D. (NPI: 1982993960) (hereinafter called “Physician”), whose principal medical office is located at 1501 Sulgrave Avenue, Suite 312, Baltimore, MD 21209
MEDICARE PRIVATE CONTRACTMedicare Private Contract • February 4th, 2020
This contract is entered into by and between Nicole J. Moss, M.D. (hereinafter called “physician”), whose principal medical office is located at 2931 N. Tenaya Way, Suite 204, Las Vegas, Nevada and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • August 13th, 2021
This agreement is entered into by and between Jason Wexler, M.D. (here in after called “Physician”), whose principal medical office is located at the above address, and
Medicare Private ContractMedicare Private Contract • October 12th, 2018
MEDICARE PRIVATE CONTRACTMedicare Private Contract • March 19th, 2021
This contract is entered into by and between Dr. Kevin Hennenhoefer, DO (hereinafter called “physician”), whose principal medical office is located at 150 Providence Road, Suite 102, Chapel Hill, NC 27514 and (hereinafter called “beneficiary”), and shall become effective on this day of , 20 and shall expire on the 30 day of April, 2023 (the “opt out period”), unless otherwise renewed in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • September 24th, 2018
This agreement is between [insert Dentists name] whose office is located at [insert clinic address], and Patient (indicated above) who is a Medicare beneficiary seeking services. The Patient has been informed that the Dentist has opted out of the Medicare Program under §1128, 1156 or 1892 of the Social Security Act effective [insert expected or known opt-out effective date] through [insert expected or known opt-out expiration date].
MEDICARE PRIVATE CONTRACTMedicare Private Contract • October 24th, 2017
This agreement is entered into by and between Lou A. Lichti, Ph.D. (hereinafter called "Psychologist"), whose principal office is located at 25 E Patrick Street, Frederick, Maryland 21701, and (a beneficiary enrolled in Medicare Part B, hereinafter called "Beneficiary"), who resides at
MEDICARE PRIVATE CONTRACTMedicare Private Contract • August 18th, 2021
This contract is entered into by and between Erin A. Reese, MD (hereinafter “Physician”), whose principal medical office is located at 19222 Stonehue, Ste. 103, San Antonio, TX 78258, and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • July 2nd, 2020
This contract is entered into by and between Piper A. Walsh, PhD (hereinafter called “physician”), whose principal medical office is located at 3551 Camino Mira Costa, Suite G, San Clemente, CA 92672, and , who resides at _, and shall become effective on this day of , 20 and shall expire on the day of
MEDICARE PRIVATE CONTRACTMedicare Private Contract • December 12th, 2001
MEDICARE PRIVATE CONTRACTMedicare Private Contract • June 10th, 2016
Ǐhis agreement is entered into by and between (hereinafter called “Mental Health Provider”), whose principal medical office is located at
AMENDMENT TO MEDICARE PRIVATE CONTRACTMedicare Private Contract • July 20th, 2012
I, the undersigned, agree to the following amendment of my Medicare Private Contract (the “Agreement”) with the Bell Center for Anxiety and Depression (the "Practice") and Elspeth Bell, Ph.D. ("Dr. Bell"):
MEDICARE PRIVATE CONTRACTMedicare Private Contract • February 29th, 2016
This agreement is between Dr. Samuel Levine whose office is located at 166 Bunn Drive, Princeton, NJ 08540, and patient (indicated above) who is a Medicare Part B beneficiary seeking services covered under Medicare Part B. I have informed my patient that I have opted out of the Medicare Program effective November 1, 2015.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • April 19th, 2022
This contract is entered into by and between Erin A. Reese, MD and Jill Vilaythong, MD (hereinafter “Physicians”), whose principal medical office is located at 19222 Stonehue, Ste. 103, San Antonio, TX 78258, and , a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (hereinafter “Beneficiary”), who resides at , and shall become
MEDICARE PRIVATE CONTRACTMedicare Private Contract • December 2nd, 2006
This agreement is entered into by and between Dr Patrick Barta, (hereinafter called "Physician"), whose principal medical office is located at Suite 401, 101 E Chesapeake Ave, Towson, MD, 21286 and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • December 14th, 2022
This agreement is entered into by and between Kevin D. Strouse, M.D. (hereinafter called “Physician”), whose principal medical office is located at 2360 W. Joppa Road, Suite 216, Lutherville,
MEDICARE PRIVATE CONTRACTMedicare Private Contract • April 11th, 2017
This agreement is entered into by and between Donald A. Rauh M.D., Ph.D., FAPA (hereinafter called “Physician”), whose principal medical office is located at 306 Floral Vale Blvd, Yardley, Pa 19067
MEDICARE PRIVATE CONTRACTMedicare Private Contract • February 17th, 2022
This contract is entered into by and between Katherine E. Watkins (hereinafter called “physician”), whose principal medical office is located at 2999 Overland Ave #201, Los Angeles, CA 90064 and (hereinafter called “beneficiary”), who resides at
MEDICARE PRIVATE CONTRACTMedicare Private Contract • September 16th, 2017
This contract is entered into by and between Douglas M. Cluff, M.D. (hereinafter called “physician”), whose principal medical office is located at 2601 Churchill Dr., Ste. 100, Flower Mound, Texas, 75028, and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • May 7th, 2013
The physician acknowledges that she is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • May 1st, 2021
Under a private contract, such as this Agreement, a Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician and to pay the physician without regard to any limits that would otherwise apply to what the physician could charge. This Agreement is limited to the financial arrangement between Physician and Patient and is not intended to obligate either party to a specific course or duration of treatment.
Medicare Private ContractMedicare Private Contract • August 3rd, 2020
This contract is entered into by and between Jared S. Putnam, MD (hereinafter called “physician”), whose principal medical office is located at 5530 Wisconsin Ave #1255 Chevy Chase MD 20815, and (hereinafter called “beneficiary”), who resides at
MEDICARE PRIVATE CONTRACTMedicare Private Contract • July 5th, 2012
A change in the Social Security Act, effective January 1, 1998, permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to charge a beneficiary more than a certain percentage in excess of the Medicare fee schedule amount (limiting charge). The law now permits physicians and beneficiaries to enter into private arrangements through a written contract under which the Beneficiary may agree to pay the Physician more than that which would be paid under the Medicare program.
University Periodontal Associates, Inc.Medicare Private Contract • November 7th, 2020
This Contractual agreement is between Dr. David K. Dennison (Dentist) whose principal place of business is at 3100 Richmond Avenue #509, Houston Texas and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • September 17th, 2012
The Physician acknowledges that he is excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. The Physician acknowledges that this contract shall not be entered into with the Beneficiary, or the Beneficiary's legal representative, during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Physician acknowledges that he must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request. The Physician shall provide a copy of this contract to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Physician
Medicare Private ContractMedicare Private Contract • December 1st, 2008
This agreement is entered into this day of , by and between Mitchell F. Reiter, M.D. (hereinafter called “Physician”), whose principal medical office is located at 33 Overlook Rd, Suite 305, Summit, NJ and
Medicare Private ContractMedicare Private Contract • September 16th, 2019
A provision in the Social Security Act permits Medicare beneficiaries and physicians/other enumerated practitioners to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician/other enumerated practitioners was not permitted to charge a patient more than a certain percentage in excess of the Medicare fee schedule amount. A new provision, which became effective on January 1, 1998, permits physicians/other enumerated practitioners and patients to enter into private arrangements through a written contract under which the patient may agree to pay the physician/practitioner more than that which would be paid under the Medicare program.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • December 12th, 2019
called “physician”), whose principal medical office is located at 208 West Columbus Avenue, Bellefontaine, OH and (hereinafter called “beneficiary”), who resides at , and shall become effective on this 1st day of January, 2020 and shall expire on the 1st day of January, 2022 (the “opt out period”), unless otherwise renewed in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • July 2nd, 2024
This Private Contract (this "Contract") is entered into by and between the undersigned physician (the "physician"), whose principal medical office is located at 6 Elm Avenue, Suite 100., Colorado Springs, CO 80906, and the undersigned patient (the "beneficiary").
MEDICARE PRIVATE CONTRACTMedicare Private Contract • November 1st, 2017
THIS CONTRACTUAL AGREEMENT IS BETWEEN DR. SHARAD PANDHI, D.D.S. (“DENTIST”) WHOSE PRINCIPAL PLACE OF BUSINESS IS AT 5828 N ORACLE RD SUITE #100, TUCSON, AZ 85704 AND (“PATIENT”). A MEDICARE PART B BENEFICIARY. AS A DENTIST THAT HAS OPTED OUT OF THE MEDICARE PROGRAM ON 07/01/2004 FOR A PERIOD OF AT LEAST 2 YEARS, DR. SHARAD PANDHI HAS INFORMED PATIENT THAT HE/SHE PROIDES TO ANY MEDICARE BENEFIIARY IS NOT SUBJECT TO MEDICARE LIMITS PERSUANT TO DENTIST “OPT OUT”AGREEMENT WITH MEDIACRE PATIENT HAS ALSO BEEN INFORMED THAT DENTIST IS PROHIBITED FROM BILLING MEDICARE FOR SERVICES PROVIDED TO PATIENT.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • September 27th, 2018
This contract cannot be entered into by the Beneficiary or his/her legal representative during a time when the Beneficiary requires emergency care services or urgent care services.
MEDICARE PRIVATE CONTRACTMedicare Private Contract • December 12th, 2001
This agreement is entered into by and between (hereinafter called “Physician”), whose principal medical office is located at
