This document is a private contract compliant with the Centers for Medicare & Medicaid Services Medicare Benefit Policy Manual, Chapter 15, § 40.8.
THIS FORM CONTAINS VERY IMPORTANT INFORMATION ABOUT YOUR MEDICARE BENEFITS. PLEASE READ IT CAREFULLY AND ASK QUESTIONS IF YOU DON’T UNDERSTAND WHAT YOU ARE BEING ASKED TO SIGN. WE CANNOT RENDER SERVICES TO YOU UNLESS AND UNTIL THIS DOCUMENT IS SIGNED.
Dale Guyer, M.D. is not a Medicare provider. Dr. Guyer has chosen to opt out of participation in the Medicare program, but is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. As a result, Dr. Guyer and you as his patient (or as such patient’s legal representative) are prohibited from submitting claims to Medicare for reimbursement for items or services provided by Dr Guyer, even though the Medicare program might otherwise cover those items or services.
In other words, all patients covered by Medicare who are provided items or service by Dr. Guyer from March 1, 2002 until current will be solely and personally responsible for payment of any and all amounts charged. By signing this form you (or your legal representative) and Dr. Guyer agree as follows:
Your Obligations
- You (or your legal representative) accept full responsibility for payment of Dr. Guyer’s charges for all items or services furnished by Dr. Guyer and understand and acknowledge that Medicare will provide no reimbursement to you or your family for such items or services.
- You (or your legal representative) understand that the Medicare limits do not apply to what Dr. Guyer may charge for the items and services furnished by Dr. Guyer to you.
- You (or your legal representative) agree not to submit a claim to Medicare for payment under the Medicare program for items or services, even if Medicare would otherwise cover such items or services.
- You (or your legal representative) agree not to request that Dr. Guyer or his staff submit a claim for payment under the Medicare program for items or services you receive, even if Medicare would otherwise cover such items or services.
- You (or your legal representative) understand that Medicare payment will not be made for any items or services furnished by Dr. Guyer that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
- You (or your legal representative) enter into this contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that you are 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.
- The expected or known effective date and the expected or known expiration date of the opt-out period is ______________, 2015 (effective date) and ______________, 2015 (expiration date).
- You (or your legal representative) 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.
- You (or your legal representative) cannot enter into this contract during a time when you 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 the Centers for Medicare & Medicaid Services Medicare Benefit Policy Manual, Chapter 15, § 40.28.)
- You (or your legal representative) acknowledge that your Medicare plan does not, and that other supplemental insurance plans may choose not to, make payment for items and services furnished by Dr. Guyer.
- You (or your legal representative) will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to you under the terms of this contract.
- You (or your legal representative) acknowledge that this written private contract contains sufficiently large print to ensure that you (or your legal representative) are able to read this contract.
Dr. Guyer’s Obligations
- Dr. Guyer acknowledges that you (or your legal representative) cannot enter into this contract during a time when you 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 the Centers for Medicare & Medicaid Services Medicare Benefit Policy Manual, Chapter 15, § 40.28.)
- Dr. Guyer will retain the original contract (original signatures of both parties required) for the duration of the opt-out period.
- Dr. Guyer will supply CMS with a copy of this contract upon request.
- Dr. Guyer acknowledges that he must enter into a private contract for each opt-out period.
