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MEDICARE PRIVATE CONTRACT
March, 2000
Medicare Private Contract
This agreement is entered into by and between
H. Berryman Edwards, MD (hereinafter called "Physician"), whose principal
medical office is located at 14535 Bel-Red Road, Suite B-200,
Bellevue, Washington 98007, and _____________________________ (a beneficiary
enrolled in Medicare Part B, hereinafter called "Beneficiary"), who resides at
_____________________________________________________________.
- Background
A change in the
Social Security Act, effective January 1, 1998, permits Medicare beneficiaries
and physicians to contract privately outside of the Medicare program. Under the
law as it existed prior to January 1, 1998, a physician was not permitted to
charge a beneficiary more than a certain percentage in excess of the Medicare
fee schedule amount (limiting charge). The law now permits physicians and
beneficiaries to enter into private arrangements through a written contract
under which the beneficiary may agree to pay the physician more than that which
would be paid under the Medicare program.
However, beneficiaries and physicians who take
advantage of this provision are not permitted to submit claims or to expect
payment for those services from Medicare. The physician has certain other
obligations, such as filing an
affidavit with the appropriate Medicare carrier(s), a copy of which is
attached to this contract. The purpose of this contract is to permit the
beneficiary and the physician to take advantage of this change in the Medicare
law and sets forth the rights and obligations of each. Furthermore, this
agreement is limited to the financial arrangement between Physician and
Beneficiary and is not intended to obligate either party to a specific course or
duration of treatment.
- Obligations of
Physician
- Physician agrees to provide such treatment as may be
mutually agreed upon by the parties and at mutually agreed upon fees.
- Physician agrees not to submit any claims under the
Medicare program for any items or services even if such items or services
are otherwise covered by Medicare.
- Physician acknowledges that (s)he will not execute
this contract at a time when the Beneficiary is facing an emergency or
urgent health care situation.
- Physician agrees to submit copies of this contract to
the Health Care Financing Administration (HCFA) upon the request of HCFA.
- Obligations of
Beneficiary
- Beneficiary or his/her legal representative agrees to
be fully responsible for payment of all items or services furnished by
Physician and understands that no reimbursement will be provided under the
Medicare program for such items or services;
- Beneficiary or his/her legal representative
acknowledges and understands that no limits under the Medicare program
(including the limits under section 1848 (g) of the Social Security Act)
apply to amounts that may be charged by Physician for such items or
services;
- Beneficiary or his/her legal representative agrees not
to submit a claim to Medicare and further agrees not to ask Physician to
submit a claim to Medicare;
- Beneficiary or his/her legal representative
understands that Medicare payment will not be made for any items or services
furnished by Physician that would have otherwise been covered by Medicare if
there were no private contract and a proper Medicare claim had been
submitted;
- Beneficiary or his/her legal representative enters
into this contract with the knowledge and understanding that (s)he has the
right to obtain Medicare-covered items and services from physicians and
practitioners who have not opted out of Medicare, and that Beneficiary is
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 of Medicare.
- Beneficiary or his/her legal representative
understands that Medigap plans (under section 1882 of the Social Security
Act) do NOT, and other supplemental insurance plans may elect not to, make
payments for such items and services not paid for by Medicare; and
- Beneficiary acknowledges that the Health Care
Financing Administration (HCFA) has the right to obtain copies of this
contract upon request.
- Physician’s Status
Beneficiary further acknowledges his/her
understanding that Physician [has/ has not] been excluded from participation
under the Medicare program under section 1128 or any other section of the Social
Security Act.
- Term and Termination
This agreement shall become effective on 3/2000
and shall continue in effect until 3/2004. Despite the term of the agreement,
either party may choose to terminate treatment with reasonable notice to the
other party. Notwithstanding this right to terminate treatment, both Physician
and Beneficiary agree that the obligation not to pursue Medicare reimbursement,
for items and services provided under this contract, shall survive this
contract.
- Successors and Assigns
The parties agree
that this agreement shall be fully binding on their heirs, successors and
assigns.
The parties hereto,
intending to be legally bound by signing this agreement below, have caused this
agreement to be executed on the date written below.
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H. Berryman Edwards, MD
Name of Physician |
Name of Beneficiary (printed) or his/her Legal Representative
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_____________________________
Signature of Physician |
_____________________________
Signature of Beneficiary or his/her Legal Representative |
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_____________________________
Date of Signature |
_____________________________
Date of Signature |
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