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
MEDICARE PRIVATE CONTRACTMedicare Private Contract • April 5th, 2023
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, 2025 (the “opt out period”), unless otherwise renewed in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D.
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 • December 12th, 2001
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
SAMPLE MEDICARE PRIVATE CONTRACT IN COMPLIANCE WITH 42 U.S.C. §1395a; 42 C.F.R. § 405, SUBPART DMedicare Private Contract • July 27th, 2020
This contract is entered into by and between [insert name of physician] (hereinafter called “physician”), whose principal medical office is located at _____________________ and [insert name of Medicare beneficiary] (hereinafter called “beneficiary”), who resides at ______________________________, and shall become effective on this __ day of _____________, 20__ and shall expire on the __ day of _____________, 20__ (the “opt out period”), unless otherwise renewed in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D.
GOOD LIFE CENTER FOR MENTAL HEALTH, LLC MEDICARE PRIVATE CONTRACTMedicare Private Contract • August 29th, 2021
This contract is entered into by and between Craig Springer, PhD (hereinafter called “provider”), whose principal medical office is located at and [insert name of
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 • January 26th, 2018
This contract is entered into by and between Wallace Taylor MD "physician", whose principal medical office is located at 3006 Bee Cave Rd, Suite A300; Austin, Texas and the Medicare beneficiary whose name appears on the accompanying signature page and shall become effective on the date of the signature sheet and shall expire on the 30th day of September, 2016 (the "opt out period"), unless otherwise renewed in accordance with the 42 U.S.C.
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.
Medical Arts Building I – Suite 305Medicare Private Contract • December 8th, 2015
FORM-8: Medicare Private ContractMedicare Private Contract • April 1st, 2019
This Medicare Private Contract is entered into by and between the below named patient and Dr. Gary Huber, Dr. Anthony Bianco and Chelsea Dorsett, R.D., L.D. as of the date set forth below.
Medicare Private ContractMedicare Private Contract • February 25th, 2015
By signing contract I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon submit) a claim to Medicare or its agents for services provided by Dr. Carlos
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 • July 20th, 2012
To be completed by Patients with Medicare currently and by Patients expecting to receive Medicare within the next 2 years
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 contract for patients 65 years and olderMedicare Private Contract • April 14th, 2015
This contractual agreement is between Dr. O’Leary (Dentist), whose principal place of business is at 9321 Martin Way E., Suite 101, Lacey, WA 98516 and (patient), a Medicare Part B beneficiary. As a Dentist that has opted out of the Medicare program on 10/1/2013 for at least two years, Dr. O’Leary has informed Patient that treatment she provides to any Medicare beneficiary is not subject to Medicare limits. Pursuant to Dentists’ “Opt Out” agreement with Medicare. Patient has also been informed that Dentist is prohibited from billing Medicare for services provided to patient. As required by law, this agreement clearly states that Dr. O’Leary is a provider in good standing with the Medicare program under section 1128, 1156, 1982 of the Social Security Act.
ContractMedicare Private Contract • November 10th, 2020
Medicare Private ContractMedicare Private Contract • November 10th, 2013
This contract is entered into by and between David R. Brown, M.D., Ph.D. (hereinafter called “physician”), whose principal medical office is located at 2401 Research Blvd., Suite 230, Rockville, Maryland 20850, and
MEDICARE PRIVATE CONTRACTMedicare Private Contract • November 14th, 2020
WHEREAS, Patient desires to be treated by Doctor with the understanding that such services will not be reimbursed by Medicare;
PRIVATE CONTRACT BETWEENMedicare Private Contract • August 14th, 2013
JOHN D. LIPANI, MD, PhD, FAANS, FACS (the “Physician”) who is employed by Princeton Neurological Surgery, P.C. (“PNS”) and practices at its office located at 3836 Quakerbridge Road, Suite 203, Hamilton, NJ 08619
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 • July 7th, 2015
This contract is entered into by and between Constance A. Johannessen, Psy.D. (hereinafter called “provider”), whose principal medical office is located at 20 Ladd St. Suite 411, Portsmouth NH 03801 and
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 • June 28th, 2016
This contractual agreement is between Dr. Bret Jacobson whose principal place of business is at 1718 S. 288th St. Federal Way, WA 98003 and a Medicare Part B beneficiary.
MEDICARE PRIVATE CONTRACT IN COMPLIANCE WITH 42 U.S.C. §1395a; 42 C.F.R. § 405, SUBPART DMedicare Private Contract • January 25th, 2019
This contract is entered into by and between Katarzyna K. Ferraro M.D. (hereinafter called “physician”), whose principal medical office is located at 9 Brookwood Avenue Carlisle Pa. 17015 and Medicare
THE MILLMAN CLINIC MEDICARE PRIVATE CONTRACTMedicare Private Contract • January 26th, 2023
