Private Contract with Medicare BeneficiaryPrivate Contract With Medicare Beneficiary • September 17th, 2020
This agreement is between Dr. Kesha Buster (“Physician”), whose principal place of business is VibrantSkin Dermatology and Laser, PLLC 11911 S. Oxford Ave Suite 200 Tulsa, OK 74137, and patient (“Patient”), who resides at
Private Contract with Medicare BeneficiaryPrivate Contract With Medicare Beneficiary • June 15th, 2020
This agreement is between Dr. Susan Schroeder (“Physician”), Perfect Skin Dermatology, P.C. at 1259 Lake Plaza Drive, Ste 270, Colorado Springs, CO 80906, and (“Patient”), who resides at and is a Medicare Part B beneficiary, pursuant to Section 4507 of the Balanced Budget Act of 1997.
Private Contract with Medicare BeneficiaryPrivate Contract With Medicare Beneficiary • March 20th, 2014
This agreement is between Colleen A. Blanchfield, M.D. (“physician”), whose principal place of business is 11490 Commerce Park Drive Suite 420 Reston, VA 20191 and the Medicare Part B beneficiary (“beneficiary”), who resides at .
PRIVATE CONTRACT WITH MEDICARE BENEFICIARYPrivate Contract With Medicare Beneficiary • July 31st, 2017
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. Physician has informed Patient that Physician 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, 1892 or any other section of the Social Security Act.
