Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial)
Non-Participation in Insurance. Patient acknowledges that neither Direct Doctors, nor the Physician, participate in any health insurance or HMO plans or panels and has opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the agreement attached as Appendix 2, and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician. You agree not to xxxx Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the agreement in Appendix 2 yearly.
Non-Participation in Insurance. The Practice does not participate with any health plans, HMO panels, or any other third-party payor. As such, we may not submit bills or seek reimbursement from any third-party payors for the Services provided under this Agreement.
Non-Participation in Insurance. Patient acknowledges that neither Practice, nor the Physicians participate in any health insurance or HMO plans. Physicians have opted out of Medicare. Patient acknowledges that federal regulations REQUIRE that Physicians opt out of Medicare so that Medicare patients may be seen by the Practice pursuant to this private direct primary care contract. Neither the Practice nor Physicians make any representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the agreement attached as Appendix 3, and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such services.
Non-Participation in Insurance. Patient acknowledges that neither Practice, nor the Providers participate in any health insurance or HMO plans. Neither the Practice nor Providers make any representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall retain full and complete responsibility for any such determination.
Non-Participation in Insurance. The Patient understands that the Practice does not participate in any government-funded or private health insurance programs, HMO panels, or any other third-party payor health plans. Therefore, the Practice may not bill or seek reimbursement from third-party payors for any of the Services included under this Agreement.
Non-Participation in Insurance. You acknowledge the Patient’s understanding that neither the CLINIC, nor its Dentist, participate in any health insurance or HMO plans or panels and can not accept Medicare payments. We make no representations that any fees that You pay under this Agreement is covered by your health insurance or other third party payment plans. It is the Patient's responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing on Your own.
Non-Participation in Insurance. You acknowledge that FCIM and its nurse practitioner do not participate in any health insurance or HMO plans or panels and has opted out of Medicare. Nothing herein or verbally discussed is to be construed as a representation that any fees due under this Agreement for anything are covered by your health insurance or other third-party payment plans applicable to you. You shall retain full and complete responsibility for any such determination. If you are eligible for Medicare, or during the term of the Agreement become eligible for Medicare, then you will sign the Agreement attached as Appendix 2 and incorporated by reference. This Agreement acknowledges your understanding that the nurse practitioner at FCIM has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the NP. You agree not to xxxx Medicare or attempt Medicare reimbursement for any services whatsoever provided hereunder. You will renew and sign the Agreement in Appendix 2 yearly.
Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither MODERN MOBILE MEDICINE, nor its Physicians, participate in any health insurance or HMO plans or panels and have opted out of Medicare. Neither make any representations that the fees paid under this Agreement are covered by the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-‐ governmental insurance plan or HSA and to submit any required billing. ______ (Initial)
Non-Participation in Insurance. Patient acknowledges that neither Inside Health, nor the Chiropractor, participate in any health insurance or HMO plans or panels and provides wellness services that are not covered under Medicare guidelines. No representation is made whatsoever that any fees paid under this Agreement are covered by your health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the Advanced Beneficiary Notice (ABN). The ABN acknowledges your understanding that the Chiropractor is providing wellness/maintenance services that are not covered by Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Chiropractor. Patient agrees not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the ABN every year thereafter chiropractic care is provided.
