Denali Medical Medicare Agreement (only needed if you are a Medicare Recipient; if you are not a Medicare Recipient, please ignore)
This agreement is between Denali Medical Services and ("Patient"), who is a Medicare Part B beneficiary seeking services covered and/or not covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. This agreement serves as notice that the Physician has informed Patient that Provider has opted out of the Medicare program effective on 11/23/15 for services rendered at Denali Medical Services 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.
Provider agrees to provide the following medical services as needed to Patient (the "Services"):
RenuO2 Injections, PRP Injections, IV Nutritionals, Supplementation
In exchange for the Services, the Patient agrees to make payments to Provider and/or Denali Medical Services pursuant to the Prescribed Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:
Leave this empty:
Your legal name
If you have questions about the contents of this document, you can email the document owner.
Document Name: Medicare Agreement
Agree & Sign