Medicare Private Contract

Dr. Tea Nguyen has opted-out of Medicare contracts and will continue to see patients who have Medicare insurance under this private contract. Effective 03/26/2021.

This agreement is between Tea Nguyen, DPM (Physician) NPI 1811282494, and (Patient) 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 and is not excluded from participating in Medicare Part B under Sections 1128, 1156 or 1892 or any other section of the Social Security Act.

Physician agrees to provide physician services to Patient. In exchange for the services, Patient agrees to make payments directly to Physician pursuant to the current Fee Schedule (the Fee Schedule includes most, but not all, common services Patient also agrees, understands and expressly acknowledges the following:

- Patient agrees to not to submit a claim (or to request that Physician submit a 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 care situation.

- Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Physician Services.

- Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program and other supplemental insurance plans may likewise deny reimbursement.

- Patient acknowledges that they have 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 or 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 services furnished by Physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.

Please sign below to acknowledge your agreement.