|Name(s) and Address of Participant*||Physician or Supplier|
|(Please Type or Print)||Identification code(s)*|
The above named person or organization, called "the participant," hereby enters into an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect.
1. Meaning of Assignment - For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment, the approved charge, determined by the Medicare carrier, shall be the full charge for the service covered under Part B. The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.
2. Effective Date - If the participant files the agreement with any Medicare carrier during the enrollment period, the agreement becomes effective on January 1, 1998.
3. Term and Termination of Agreement - This agreement shall continue in effect through December 31 following the date the agreement becomes effective and shall be renewed automatically for each 12-month period January 1 through December 31 thereafter unless one of the following occurs:
a. During the enrollment period provided near the end of any calender year, the participant notifies in writing every Medicare carrier with whom the participant has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the end of the current term. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calender year, the agreement shall end on December 31 of that year.
b. The Health Care Financing Administration may find, after notice to and opportunity for a hearing for the participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is made, the Health Care Financing Administration will notify the participant in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement.
|Signature of participant||Title||Date|
|(or authorized representative||(If signer is authorized|
|of participating organization)||representative of organization)|
Office hone number (incluing area code)
Received by _________________________ (name of carrier)
Effective date _________________________
Initials of carrier official
*List all names and identification codes under which the participant files claims with the carrier with whom this agreement is being filed.