Medicare Opt Out Form?
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Does anyone have a form/template for Medicare-eligible clients to complete to declare that they are opting to self-pay as opposed to using their Medicare benefits? I have completed the opt-out process with Medicare as a provider, but I am aware that I also need my clients to complete an additional form acknowledging that they are opting out of using Medicare benefits when they choose to work with me.
Thank you!
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Per the information that I have received, affidavits now auto-renew every 2 years (historically there was a need to re-apply periodically, but that was changed in 2015). https://med.noridianmedicare.com/web/jeb/enrollment/opt-out#private_contract
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Hi Corrie, I have recently done this. If you have already received confirmation from regional medicare contractor (MCO) that you are no longer a participating provider, you need to sign a private contract with the patient. Here is a link to Sample contract form. This needs to be signed every 2 years by patient. (even though for physician renewal no longer needed). this is an external link
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- "After filing this Affidavit with Medicare, download the Medicare Private Contract from your Medicare MAC website, and have each of your private Medicare clients sign this, notifying them that Medicare will not reimburse them."
This form is what I am looking for and would like to have in the portal to have client sign if they are medicare age. Is this what you have linked to above or is their a simpler form/notification clients can sign?
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