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. The Physician has informed Patient that Physician has opted out of the Medicare program originally effective on November 4, 2004. Physician opts out every two years. Physician agrees to provide medical services to Patient. In exchange for the Services, the Patient agrees to make payments to the Physician pursuant to the Fee Schedule upon completion of services provided. Patient also agrees, understands, and expressly acknowledges the following: • Patient agrees 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 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 he/she 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 or practitioners who have opted-out. • Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that the 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 were no private contract and a proper Medicare claim were submitted. • Patient acknowledges that a copy of this contract has been made available to him/her.
Executed on 05/04/2022 by and Dr. Lang, D.O.
WE ARE NOT PROVIDERS WITH ANY INSURANCE GROUP PAYMENT FOR PROFESSIONAL SERVICES IS DUE AT THE TIME TREATMENT IS RENDERED.
FOR YOUR CONVENIENCE, WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER & HEALTH SAVINGS ACCOUNT CARDS.
IF YOU HAVE MEDICAL INSURANCE THAT YOU WOULD LIKE TO FILE, YOU WILL BE GIVEN A RECEIPT UPON CHECKING OUT THAT WILL ENABLE YOU TO FILE YOUR CLAIM WITH EASE.
PLEASE REMEMBER THAT YOUR INSURANCE POLICY IS AN AGREEMENT BETWEEN YOU AND YOUR INSURANCE COMPANY. YOU ARE RESPONSIBLE FOR PAYMENT OF ALL CHARGES AT THE TIME OF SERVICE.
PLEASE DON’T HESITATE TO ASK ANY OF OUR STAFF FURTHER QUESTIONS THAT YOU MAY HAVE. CINDY, OUR OFFICE MANAGER, IS ALSO AVAILABLE TO ASSIST YOU WITH ANY QUESTIONS OR CONCERNS YOU MAY HAVE.
Thank you,
Dr. Howard J. Lang, D.O.
Dr. Derek H. Lang, D.O.
I understand that my signature represents that I have read and understand the above policies (HIPAA, MEDICARE, PRIVACY ETC.). I agree to make payment in full at the time of my office visit(s).