I provide this Request and Consent to protect my future access to private medical care based on payments using Medical Savings Accounts or other private payment methods. I request and consent that the medical office of Dr. ____________________ ("this private physician") provide medical services to me outside of the Medicare and other government programs in emergency and non-emergency circumstances. I acknowledge and consent that no documentation will be provided for such services to enable reimbursement from Medicare or other governmental programs.

Neither I nor my heirs, executors, administrators, successors, beneficiaries, or assigns will submit a claim (or request that a claim be submitted) for services provided by this private physician. I acknowledge that such services may fall within the scope of Medicare or other governmental programs, and that I have the right to seek such services from other providers if I wish to obtain reimbursement by the government. I consent that the fees charged by this private physician for such services may be greater or less than limiting charges established by Medicare or other programs.

I hereby acknowledge and consent that this private physician is justified in relying upon this Request and Consent in providing all future services to me, whether during an emergency or not. In the event that I take any action contrary to this Request and Consent which causes administrative or legal expense to this private physician, I will provide reasonable reimbursement.

Patient's Name ___________________________________

Patient's Signature ______________________________ Date ________________