Dear Patient,

 

As a Medicare beneficiary you are entitled to specific Medicare benefits and beholden to Medicare guidelines.  This Medicare Supplemental Policy is intended to clarify any potential questions or concerns.     

 

MEDICARE:

 

If you are or become Medicare eligible, you acknowledge that I am a participating Medicare provider, and as required by law, I will submit reimbursement claims to Medicare for all Medicare-covered services provided to you. You shall not submit to Medicare any claim for payment of fees for services provided by me. You acknowledge and understand that Medicare will not pay for the Wellness Services referenced in Schedule A, and you agree not to request Medicare reimbursement for Wellness Services.

 

For Medicare eligible patients, and with respect to any services other than the Wellness Services identified in Schedule A, I may deliver services specifically covered by Medicare at your request and as medically indicated and consistent with Medicare requirements including but not limited to the Welcome To Medicare Checkup, the Annual Wellness Visit, and telehealth evaluation and management, which are covered by Medicare—all such services are not part of the private Wellness Services fees identified above.

 

PATIENT ACKNOWLEDGES THAT HE/SHE/THEY HAS/HAVE CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER/THEIR CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTANDS HIS/HER/THEIR RESPECTIVE RIGHTS AND OBLIGATIONS UNDER THIS AGREEMENT, AND SIGNS THIS AGREEMENT OF HIS/HER/THEIR OWN FREE WILL AND VOLITION.

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Schedule A Wellness Services
 

• Routine physical examination

• Health screening beyond national guidelines recommendations

  • Galleri cancer testing

  • Myriad cancer screening

• Routine annual screening labs

• Pre-travel medical consultations