PATIENT MEDICARE OPT OUT FORM

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 Beneficiary or his/her legal
representative that Physician has opted out of the Medicare program effective on March 15, 2016. The
physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892]
1892 of the Social Security Act.

Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:

Beneficiary or his/her legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.

Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician. 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.

Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the
physician to submit a claim to Medicare.

Beneficiary or his/her legal representative 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 was no private contract and a proper Medicare claim had been submitted.

Beneficiary or his/her legal representative enters into this contract with the knowledge that he/shehas the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary 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.

Beneficiary or his/her legal representative understands that Medi-Gap plans do not, and that
other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.

Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made
available to him/her.

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