This agreement is between Dr. Susan Schroeder (“Physician”), Perfect SkinDermatology, P.C. at 1259 Lake Plaza Drive, Ste 270, Colorado Springs, CO 80906,and _______________________________________ (“Patient”), who resides at _____________________________________ and is a Medicare Part B beneficiary, pursuant to Section 4507 of the Balanced Budget Actof 1997.

The Patient has been informed that Physician has opted-out of Medicare effective on July 1, 2020 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”):

  • Medical and surgical dermatology (care of skin, hair and/or nails).

In exchange for the Services, the Patient agrees to make payments to Physicianpursuant to the Perfect Skin Dermatology current fee schedule (posted on the practice website).

Patient also agrees, understands, and expressly acknowledges the following:

  • Patient will not submit a claim (or to request that Physician submit a claim) to Medicare for any services received at Perfect SkinDermatology, even if those services are 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 theServices.
  • 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/she 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, for 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/her.
  • Patient agrees to reimburse Physician for any costs and reasonable attorneys’ fees that result from a violation of this Agreement by thePatient or his/her beneficiaries.

Executed on ______________________________

Date

by:_____________________________

Patient Name

________________________

Patient Signature

and: Susan Schroeder, MD____________________________________

Physician Signature