Medicare Private Contract

Private Contract between a Medicare Beneficiary and Arvinder Walia MD

Please correct the errors described below.
  • Arvinder Walia MD has opted out of Medicare.
  • Arvinder Walia MD is excluded from Medicare under sections 1128, 1156 or 1892 of SSA.
  • Patient/Legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
  • Patient/Legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
  • Patient/Legal representative agrees to not to submit a claim to Medicare or ask the physician to submit a claim to Medicare.
  • Patient/Legal representative 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 submitted.
  • Patient/Legal representative enters into the contract with the knowledge that the patient has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and 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/Legal representative understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
  • Patient/Legal representative understands that this contract is entered in non emergency care setting.
  • Patient/Legal representative acknowledge that this contract was furnished prior to providing the services.
  • Patient/Legal representative understands that this contract will be retained by Arvinder Walia MD for the duration of opt out.
  • Patient/Legal representative understands that this contract will be available for CMS to review upon request.

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

Your message will be encrypted.