To submit this form, you need to ensure all fields are filled out correctly, with the necessary signatures included. The completed form must be submitted to the local Medicare carrier, either through fax or mail. Please address submissions to the appropriate CMS office as indicated, ensuring compliance with submission guidelines.

As of now, no specific important dates for this form have been highlighted for 2024 and 2025. It's essential to stay updated regularly for any changes in the Medicare regulations that may affect this form.

The purpose of this form is to establish a legally binding agreement between Medicare beneficiaries and providers opting out of Medicare services. It outlines the responsibilities and rights of both parties under the Medicare system. By properly filling out this form, beneficiaries are made aware of their options in navigating medical services not covered by Medicare.

• 1. Provider's Name: Enter the full name of the healthcare provider.
• 2. Beneficiary's Name: Specify the full name of the Medicare beneficiary.
• 3. Provider's NPI: Include the unique National Provider Identifier for the provider.
• 4. Signatures: Signatures are required from the provider, beneficiary, and witness.
• 5. Effective Date: Indicate the start date for the opt-out period.
• 6. Expiration Date: Fill in the end date for the opt-out period.
• 7. Provider's Specialty: Describe the medical specialty of the provider.
• 8. Contact Information: Provide contact details for further communication.

Failure to submit this form could lead to confusion regarding service payments and responsibilities. Without proper documentation, Medicare may deny coverage for services rendered under private contracts. This can result in unexpected financial liabilities for both patients and providers.

• Confusion in Billing: Without proper submission, there may be unclear billing practices leading to disputes.
• Potential Denial of Claims: Services provided may not be covered by Medicare if the form is not submitted.
• Legal Implications: Failure to document agreements can lead to legal misunderstandings.

• 1. Private Contracting with Medicare Providers: When beneficiaries opt to receive services from providers who have chosen to opt-out of Medicare.
• 2. Non-Covered Services Agreements: For services that Medicare does not cover but are needed by beneficiaries.
• 3. Legal Representation Contracts: Guidance for beneficiaries needing representation in private agreements.