Sample Medicare Opt-Out Forms

These form are successfully used by a practicing physician

Click here to return to main information page on opting out of Medicare.

  • Medicare Opt-Out – General Guidelines
    This is a basic document to explain how to use the other forms.
    Word Format PDF FORMAT

  • Opt-Out – Physician – standard
    Physician contract
    Word Format PDF FORMAT

  • Opt-Out – Patient – standard
    Patient contract
    Word Format PDF FORMAT

  • Medicare Beneficiary Claim Form
    Medicare patients can sometimes receive some reimbursement from Medicare secondary payors (depending on individual contracts), by filing a claim with the Medicare contractor for "denial purposes only." Once Medicare denies the claim (because you are opted out), it can be sent on to the Medicare secondary payor. Some Medicare contractors will automatically forward the claim, and some will not. If they do not forward the claim, then the patient can forward the denial letter from Medicare with the claim form.

    The 1490S claim form is the form that patients have used to file their own claims to Medicare "for denial purposes only." Patient’s Request for Medical Payment – This form is from the Medicare website and patients can send this form to Medicare, in order to get a denial of their claim, which can in turn be sent to their secondary insurance for possible payment. Most secondary carriers want to see a denial from the primary before they will process a claim. Since the provider cannot file the claim, the patient may use this form to obtain the denial.
    1490S Form PDF FORMAT

    You should also give the patient a cover letter to send with the 1490S, so the Medicare contractor will know what is going on.
    Word Format PDF FORMAT

  • Medicare Manual – Opt-out Guidelines – Denials to Beneficiaries
    This is document created to help patients if Medicare refuses to give them a written denial. This information came straight from the Medicare Policy Manual and cites the exact denial code that is supposed to be sent in a written notice to the patient.
    PDF FORMAT

  • Attention Insurance Carrier – Send payment to patient
    Give this form to patients to attach to their claim, hoping that the insurance carrier will send payments for non-assigned claims directly to our patients
    Word Format PDF FORMAT

  • New Patient Form – Introduction and Financial Policy
    Introduction explains why we are Third-Party Free and Financial Policy covers several situations that have taught us hard lessons in the past, Re: accident cases, etc.
    Word Format PDF FORMAT

  • Labels-Assignment Not Accepted
    We print these labels to put on claim forms, hoping that the insurance carrier will send payments for non-assigned claims directly to our patients
    Word Format PDF FORMAT

  • Letter – Returning Insurance Payment
    We send all insurance payments back, if the money is not owed to our clinic. The letter gives a detailed explanation of the logic behind this policy.
    Word Format PDF FORMAT

  • Patient Instructions for Verifying Ins Benefits
    We try to make it simple for patients to obtain and understand their insurance benefits, and develop some understanding of how their insurance carrier will handle their claims.
    Word Format PDF FORMAT