Private Contract For Medicare Patients

Private Contract for Medicare Patients

Doris Lebischak, MD is not a Medicare participating physician. I have elected to opt out of participating. Any recommendations that I make will be covered under Medicare Payment for Services.

· You agree to enter into a private contract with me that is permissible under the Social Security Act.

· You agree to accept full responsibility for payment of all services furnished by myself.

· Medicare limits do not apply. I may charge for items or services furnished.

· I, _____________________________, agree not to submit a claim to Medicare or ask the physician to submit a claim to Medicare.

· The state will not reimburse for any Medicare payments. My opt out period will be effective until May 1, 2009. I understand that Medigap plans do not make payment for items and services not paid by Medicare.

· I understand that this cannot be entered into at a time of emergency.

· I agree that I have been provided a copy of this statement.

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Doris Lebischak, MD

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Patient Date