PRIVATE CONTRACT WITH MEDICARE BENEFICIARY
This agreement is between Dr. David Schechter, whose principal place of business is 10780 Santa Monica Blvd #300 Los Angeles, CA 90025, and patient _______ ________
First Last
Who resides at ____________
example: 111 Bird Ln., Encino, CA 91111
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 10-01-2024 for a period of at least two years and is not excluded from participating in Medicare Part B under sections 1128,1 156,1892 or any other section of the Social Security Act.
Physician agrees to provide the following medical services to patient (the "Services"): Evaluation & Management, Consultation, and Professional Component Services. In exchange for the services, the patient agrees to make payment to Physician pursuant to the Physicians Fee. Estimates are available upon request.
Patient also agrees, understands and expressly acknowledges the following:
Patient agrees not to submit a claim (or requests that Physician submits claim) to the Medicare program with respect to the services, even if covered by Medicare part B. Patient is not currently in an emergency or urgent health situation. Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the services. Patient acknowledges that Medi-Gap plans will not provide payment nor reimbursement for the services because payment is not made under the Medicare program and other supplemental insurance plan may likewise deny reimbursement. Patient acknowledges that she or he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians and practitioners who have not opted out. Patient agrees to be responsible to make payment in full for the services and acknowledges that Physician will not submit a Medicare claim for the services and that no Medicare reimbursement will be provided. Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim was submitted. Patient acknowledges that a copy of this contract has been made available to him or her. Patient agrees to reimburse Physician for any costs and reasonable attorney fees that result from violation of this agreement by Patient or his beneficiaries.
Today's date
Patient/Guarantor name
Patient/Guarantor Signature
