Medicare benefits policy manual chapter 15

Call Today Guyer agree as follows: Your Obligations You or your legal representative accept full responsibility for payment of 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.

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.

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. 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 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.

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. 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.

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.

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. Guyer will retain the original contract original signatures of both parties required for the duration of the opt-out period.