Medicare Opt Out Form?

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Corrie A. Goldberg

• August 23, 2019 12:35

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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  Susan Orenstein

  • August 23, 2019 17:35

  I have the same question.  This would be great information to have.

  And I have an additional question--how do you renew the opt-out process with Medicare?  And how often is it necessary to renew this?

   

  Thanks!!

   

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  Corrie A. Goldberg

  • August 23, 2019 17:42

  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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  Susan Orenstein

  • August 23, 2019 18:56

  thanks!

   

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  Sanjeev Singhal MD

  • September 10, 2019 11:03

  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

  https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjY0OyXjcbkAhVNm-AKHauEBpoQFjAAegQIARAC&url=https%3A%2F%2Fwww.aafp.org%2Fdam%2FAAFP%2Fdocuments%2Fpractice_management%2Fregulatory_compliance%2FMedSampContractAff.doc&usg=AOvVaw1fSmpf48T37gwKP5xWqIRF

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