For Medicare Patient Form

FOR MEDICARE PATIENTS

I requested that payment of authorized Medicare benefits be made to Gibbons Foot and Ankle Group for any services furnished by said physician and/or supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and/or its agents regarding any information needed to determine these benefits or the benefits payable for related services.

I understand that Medicare will only pay for services that it determines to be reasonable and necessary under Section 1862(a) of the Medicare law. If Medicare determines that a particular service, although it would be otherwise covered is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service. We believe that in your case, Medicare is likely to deny payment for Debridement of Mycotic Nails for the following reasons: Medicare usually does not pay for like services by more than one doctor during the same time period and/or Medicare usually does not pay for this many services within this period of time.

BENEFICIARY AGREEMENT

I have been notified by my physician that he believes that, in my case, Medicare is likely to deny payment for the services identified above, for the reasons stated. If Medicare denies payment I agree to be personally and fully responsible for payment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.