Effective Date 30/09/2025

Consent For Patients Over 65 Years Old

Medicare Private Contract must be signed by those 65 years and older. Could create a filter to require this only to those patients, or just have everyone sign it and change the language to 

This Private Contract is entered into between the undersigned physician (“Physician”) and the undersigned patient (“Patient”).

1. Required Disclosures.

As required by federal law and Centers for Medicare & Medicaid Services (“CMS”):

  1. Patient and Physician agree that neither will submit a claim to Medicare for payment for the services provided under this contract.

  2. Patient agrees to be fully responsible for payment for the services provided by Physician, even though the Patient may otherwise be eligible for Medicare benefits.

  3. Patient understands that Medicare payment will not be made for any items or services provided by Physician under this contract, even if such services would otherwise have been covered by Medicare.

  4. Patient acknowledges that they have the right to obtain Medicare-covered services from other physicians or practitioners who have not opted out of Medicare, and who can submit claims to Medicare.

  5. Patient acknowledges that Physician has opted out of Medicare and is not limited by Medicare fee schedules, balance billing limits, or other restrictions.

  6. Patient understands that this agreement applies only to services furnished by the contracting Physician, not to services furnished by other providers.

2. Term and Effectiveness.

This contract shall remain in effect for a period of two (2) years from the date of execution, unless terminated earlier in accordance with applicable law. This contract applies to all services furnished by Physician to Patient during the contract term.

3. No Emergency Care Limitation.

This agreement does not apply to emergency or urgent care services provided to the Patient. Medicare coverage rules will still apply in those circumstances.

4. Acknowledgments.

By signing below, Patient confirms that they:

  • Have read and fully understood this contract;

  • Enter into this contract voluntarily;

  • Understand that Medicare cannot be billed or reimbursed for any services provided by Physician under this agreement.