Common use of Medicare Clause in Contracts

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has Physicians have opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the PhysicianPhysicians. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D 4 and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D 4 and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx bill Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has Physicians have opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the PhysicianPhysicians. The Patient agrees not to xxxx bill Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D 4 and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement Your initials on this clause of the Agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ law (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ law (Initial)) 2 v2 8/5/17

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has Physicians have opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the PhysicianPhysicians. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the agreementacknowledgesthe Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the PatientMember’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient Member by the Physician. The Patient Member agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient Member is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient Member shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the Patient’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Physician. The Patient agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D 4 and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)

Medicare. This agreement acknowledges the PatientMember’s understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient Member by the Physician. The Patient Member agrees not to xxxx Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient Member is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient Member shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law. ______ (Initial)