Patient Forms

Medicare Opt Out Contract

“This agreement is between Dr. Lawrence Huntoon (“Physician”), whose principal place of business is Chapel Park Villa, 7008 Erie Rd., Suite #6, Derby, NY 14047, and patient_______________________________(“Patient”), who resides at ________________________________________________ and 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 02/15/2004 (updated 02/15/2008) 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): Consultation, office visits, house calls, neurologic diagnostic services (EMG/NCV, VER, BAER, SSEP), bioethics consultation.

In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the attached fee schedule. Patient also agrees, understands and expressly acknowledges the following: [ask Patient to initial each one below:]

______Patient agrees not to submit a claim (or 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 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 attorney’s fees that result from violation of this Agreement by Patient or his beneficiaries.

Executed on __________________(Date)

by ___________________________________(Patient Name)

and

Lawrence R. Huntoon, M.D., Ph.D., F.A.A.N. (Physician Name)

___________________________________

[Patient Signature]

___________________________________

[Physician Signature]

Medicaid Opt Out Contract

“This agreement is between Dr. Lawrence Huntoon (“Physician”), whose principal place of business is Chapel Park Villa, 7008 Erie Rd., Suite #6, Derby, NY 14047, and patient_______________________________(“Patient”), who resides at ________________________________________________ and is a Medicaid beneficiary seeking services as a private pay patient. The Physician has informed Patient that Patient has the right to see a physician who participates in Medicaid and agrees to accept the Medicaid payment as payment in full. By signing this Medicaid Opt Out Contract, Patient understands and agrees that Patient will be treated on a private pay basis by Dr. Huntoon, and that no Medicaid claim will be filed.

______Patient agrees not to submit a claim (or request that Physician submit a claim) to the Medicaid program with respect to the Services, even if covered by Medicaid.

______Patient is not currently in an emergency or urgent health care situation.

______Patient acknowledges that neither Medicaid’s fee limitations nor any other Medicaid reimbursement regulations apply to charges for the Services.

______Patient acknowledges that secondary insurance plans will not provide payment or reimbursement for the Services because payment is not made under the Medicaid program, and other supplemental insurance plans may likewise deny reimbursement.

______Patient acknowledges that he has a right, as a Medicaid beneficiary, to obtain Medicaid-covered items and services from physicians and practitioners who have not opted-out of Medicaid, and that the patient is not compelled to enter into private contracts that apply to other Medicaid-covered services furnished by other physicians or practitioners who have not opted-out.

______Patient agrees to be responsible, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicaid claim for the Services and that no Medicaid reimbursement will be provided.

______Patient understands that Medicaid payment will not be made for any items or services furnished by the Physician that would have otherwise been covered by Medicaid if there were no private contract and a proper Medicaid 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 attorney’s fees that result from violation of this Agreement by Patient or his beneficiaries.

Executed on __________________(Date)

by ___________________________________(Patient Name)

and

Lawrence R. Huntoon, M.D., Ph.D., F.A.A.N. (Physician Name)

___________________________________

[Patient Signature]

___________________________________

[Physician Signature]