Medicare Benefit Waiver

Effective July 1, 2007, Statesboro Psychiatric Associates (SPA) opted out of Medicare, and does not participate with Medicare, its Supplements or any of the Medicare Commercial Insurance Products.

I recognize that SPA will not file claims with Medicare or Commercial Medicare policies, and I agree to waive my Medicare benefit, and will not file claims with Medicare or its commercial products for visits to SPA.

I understand that since I cannot file with Medicare for SPA services, I will not be provided with filing information such as provider NPI numbers and CPT coding.

I accept the responsibility of full payment for my visits based on the practice fee schedule, and understand that the practice fee schedule is not subject to Medicare rates or limitations. This includes any charges for missed appointment without 24-hour notification.

I understand that because my claims will not be filed with Medicare, they also will not be filed with any supplemental or secondary insurance I may have.

I understand that I have the option of choosing a practice that does participate with Medicare and its products, but have chosen to be seen at SPA, and understand that in doing so I waive my Medicare and supplemental/secondary insurance benefits.

Patient Name

DOB

Name of Responsible Party (if not the patient)

Signature of Responsible Party/Patient

Date

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