EFTA00314071.pdf

Darius Paduch, M.D. 525 East 68'h Street, Starr 900 New York, NY 10065 till aIIII 2935318 ERSTEIN,JEFFREY 01/20/1953 Initial:___ - - Date: This agreement is between Darius Paduch, M.D., whose principal place of business is 525 East 68th Street New York, NY 10065, and Beneficiary: Who resides at: Medicare ID N: jef"FiR EA, &-P -re.:4,.1 q 2AR-r -9-1 3T ST , m y IQ 0,3-1 and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on July 1, 2014 for a period of at least two years, to expire on July I, 2016. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act. Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following: Beneficiary or his/her legal representative accepts full responsibility for payment of the physician's charge for all services furnished by the physician. (\y Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physici Beneficiary or his/her legal representative agrees not to submit a claim to Mitre or to ask the physician to submit a claim to Medicare. Beneficiary or his/her legal representative understands that Medicare payment will nkt be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. Beneficiary or his/her legal representative eaten into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary 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. EFTA00314071