MEDICARE PRIVATE CONTRACT
Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary. I understand that the Physicians at Anchor Medical Group (AMG) have not been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act. I (the Medicare beneficiary named above or my legal representative) accept full responsibility for payment of charges for all services furnished by AMG. I understand that Medicare limits do not apply to what AMG may charge for items or services furnished. I agree not to submit a claim to Medicare or to ask AMG to submit a claim to Medicare. I understand that no coding documentation will be provided to me for such services to enable reimbursement from Medicare or other federal programs. I understand that Medicare payment will not be made for any items or services furnished by AMG that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
I enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare. I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. I understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare
This contract cannot be entered into by me, the Medicare beneficiary, or by my legal representative, during a time when I require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual.) I will receive or have received a copy of this contract upon request, before items or services are furnished to me under the terms of this contract.
I understand that a copy of this contract will be retained by AMG for the duration of the opt-out period. The current private contract remains in effect for two years and is expected to renew indefinitely. A copy of this contract is available to CMS upon request.
I certify that I have read and understand the above document.
BY TYPING MY NAME ABOVE , I CERTIFY THAT THIS REPRESENTS MY ELECTRONIC SIGNATURE AND IS THEREFORE LEGALLY BINDING
