Medicare Opt Out Form

Medicare Opt Out Form
Please fill out the form below to opt out of Medicare.
Provider Information
Provider Name (Individual or Group)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Opt-Out Declaration:
I, the undersigned healthcare provider, hereby choose to opt out of the Medicare program for all services I furnish. I understand that by opting out, I will not be able to bill Medicare or receive Medicare reimbursement for services provided to Medicare beneficiaries.
Effective Date of Opt-Out:
MonthDayYear
This date should be at least 30 days after the submission of this form to allow for proper notification to Medicare beneficiaries.
Acknowledgment of Responsibilities
I acknowledge that, as an opted-out provider, I will not enter into private contracts with Medicare beneficiaries for the services I furnish unless I have filed an affidavit of private contract with Medicare. I also understand that I am responsible for providing written notice to all Medicare beneficiaries, in advance, of their right to enter into a private contract with me for covered services.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Provider Information