Medicare Agreement

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:

  • Patient agrees not to submit a claim (or to request that Provider 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 Providers 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 Providers 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 Provider will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided
  • Patient understands that Medicare payment will not be made for any items or services furnished by the Provider 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/her
  • Patient agrees to reimburse Provider for any costs and attorneys' fees that result from violation of this Agreement by Patient or his beneficiaries

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Signature Certificate
Document name: Medicare Agreement
lock iconUnique Document ID: cede6fe91ebbb34031d771ce80366575ed9aa9d7
Timestamp Audit
July 10, 2019 8:15 pm MDTMedicare Agreement Uploaded by Lisa Strauss - IP
July 10, 2019 8:40 pm MDTCindy Meldrum - added by Lisa Strauss - as a CC'd Recipient Ip: