PRIVATE CONTRACTPrivate Contract • April 19th, 2022
This Agreement is between James Neuenschwander, M.D. ("Dr. Neuenschwander"), whose principal place of business is 4201 Varsity Dr., Ann Arbor, MI 48108, and
PRIVATE CONTRACTPrivate Contract • July 2nd, 2018
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.
PRIVATE CONTRACTPrivate Contract • June 30th, 2022
Private Contract Between Medicare Beneficiary and Physician/PractitionerPrivate Contract • June 2nd, 2018
The beneficiary or his/her legal representative (named below) understands that Medicare limits do not apply to what I may charge for items or services furnished by me.
Private ContractPrivate Contract • April 30th, 2018
This private contract (“Contract”) is between Jared Heathman, M.D. (“Physician”), whose principal place of business is 12250 Queenston Blvd. Ste E, Houston, TX 77095, and:
Private ContractPrivate Contract • June 18th, 2020
• I the Medicare beneficiary or my legal representative accept full responsibility for payment of charges for all services furnished by Paul P. Roberts, M.D.
Private ContractPrivate Contract • April 4th, 2023
This agreement is between Ray McClanahan, D.P.M., whose principal place of business is 2701 NW Vaughn Street, Suite 424, Portland, OR 97210 and
ContractPrivate Contract • February 17th, 2013
MEDICARE PRIVATE CONTRACTPrivate 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].
Private Contract between a Medicare Beneficiary and Arvinder Walia MDPrivate Contract • February 4th, 2019
• Patient/Legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
Holistic Child Psychiatry, LLC Phyllis J. Heffner, M.D.Private Contract • April 6th, 2020
Toni J. Camp MD Three Calle San Martin Santa Fe, NM 87506Private Contract • January 4th, 2016
Toni J. Camp, MD, has excluded herself (opted-out) from Medicare under [1128] §§1128, [1156] 1156 of [1892] 1892 of the Social Security Act. This document then is a private contract compliant with §40.8 of the Medicare benefit policy manual, Chapter 15.
MURPHY PAIN CENTER PRIVATE CONTRACTPrivate Contract • April 3rd, 2021
Pamela Gallup Gaudry, M.D., NCMP, FACOGPrivate Contract • March 14th, 2018
This agreement is between Pamela Gallup Gaudry, M.D., NCMP, FACOG whose principal place of business is 15 Lake Street, Suite 160, Savannah, Georgia, 31411 and
PRIVATE CONTRACT – PROVIDER OPT-OUT OF MEDICAREPrivate Contract • September 5th, 2024
This agreement is between Dr. Matthew Russo (“Physician”) and patient (“Patient”). The 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. Physician has informed Patient that Physician has opted out of the Medicare program effective on January 1, 2025 for a period of at least two years until January 1, 2027. The above noted Physician is not and has not been excluded from participating in Medicare Part B under Sections 1128, 1156, 1892 or any other section of the Social Security Act.
Private ContractPrivate Contract • August 7th, 2018
This agreement is between Ray McClanahan, D.P.M., whose principal place of business is 2701 NW Vaughn Street, Suite 424, Portland, OR 97210 and
David D. Richardson, M.D.Private Contract • June 20th, 2008
ContractPrivate Contract • December 23rd, 2022
Between The Bridges Healing Center LLCPrivate Contract • September 17th, 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 Beneficiary or legal representative that Physician has opted out of the Medicare program effective January 1, 2018 for a period of at least two years to expire on December 31, 2019. The Physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
Private ContractPrivate Contract • February 1st, 2022
who 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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2015. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
MEDICARE PRIVATE CONTRACTPrivate 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.
DAVID D. RICHARDSON, M.D., INC.Private Contract • October 7th, 2015
Nancy C. Wheeler, M.D.Private Contract • September 25th, 2024
This agreement is between Nancy C. Wheeler, M.D., whose principal place of business is 133 Defense Highway, Suite 114; Annapolis, MD 21401, and
Amy Huberman, M.D.Private Contract • June 14th, 2023
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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2021. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
PRIVATE CONTRACTPrivate Contract • February 15th, 2017
This Private Contract/agreement is between Kerri Lou Williams, D.O. (“Physician”), whose principal place of business is 2301 SE Washington Blvd., Bartlesville, Oklahoma 74006, and Patient
Amy Huberman, MD www.amyhubermanmd.com 1829 Reisterstown Rd, Suite 350Private Contract • September 20th, 2024
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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2021. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
PRIVATE CONTRACTPrivate Contract • September 19th, 2022
This contract is entered into by and between Evan L. Jacobson, M.D. (hereinafter called “physician”), whose principal medical office is located at 3801 PGA Blvd., Suite 600 Palm Beach Gardens, FL 33410, and
Private ContractPrivate Contract • May 24th, 2019
• I, (client’s name)_______________________________, the Medicare beneficiary, or my legal representative accept full responsibility for payment of charges for all services furnished by Deborah Buckwalter, Ph.D.
Amy Huberman, M.D.Private Contract • January 15th, 2021
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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2021 for a period of at least two years. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
Private ContractPrivate Contract • November 16th, 2023
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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2021. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
Private ContractPrivate Contract • April 24th, 2018
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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on April 1, 2016 for a period of at least two years, with automatic renewal on April 1, 2018 for at least another two years. The physician is not excluded from participating in Medicare Part B under Sec.1128, 1156, or 1892 of the Social Security Act.
PRIVATE CONTRACTPrivate Contract • June 13th, 2016
Private ContractPrivate Contract • June 1st, 2017
This agreement is between Ray McClanahan, D.P.M., whose principal place of business is 2701 NW Vaughn Street, Suite 424, Portland, OR 97210 and
PRIVATE CONTRACTPrivate Contract • May 20th, 2019
This Private Contract/agreement is between Kerri Williams, DO, MHA, FAAFP (“Physician”), whose principal place of business is 2301 SE Washington Blvd., Suite A, Bartlesville, Oklahoma 74006, and (“Patient”), who resides at
Private ContractPrivate Contract • April 4th, 2023
This agreement is between Northwest Foot and Ankle, LLC, whose principal place of business is 9600 SW Nimbus Ave, Suite 160, Beaverton, OR 97008 and
