This agreement is between Christopher Charles M.D. and Kimberlee
Charles M.D. (“Physician”), and you (“Patient”) who
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 effective
on 1/1/2018 for a period of at least two years, and is not excluded from
participating in Medicare Part B under Sections 1128, 1156, or 1892 or any
other section of the Social Security Act.
Physician agrees to provide the following medical services to
Patient (the “Services”):
Psychiatric Evaluation, Psychotherapy, Psychiatric Medication
Management
In exchange for the
Services, the Patient agrees to make payments to Physician pursuant to the
Attached Fee Schedule.
Psychiatric Evaluation
: $400
Psychotherapy:
$275/session
Psychiatric Medication
Management: $185/session
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 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
not opted-out.
- Patient
agrees to be responsible, whether through insurance or otherwise, to make
payment in full for the Services, and acknowledges that Physician will
not submit a Medicare claim for the Services and that no Medicare
reimbursement will be provided.
- Patient
is aware that secondary insurance plans will and cannot be billed by the
provider or by the patient if patient Medicare policy is primary.
- 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.
- Patient
agrees to reimburse Physician for any costs and reasonable attorneys’ fees
that result from violation of this Agreement by Patient or his
beneficiaries.
