Get Affidavit Form - Palmetto Gba

Filling out the Affidavit Form - Palmetto GBA online is a crucial step for healthcare providers opting out of Medicare participation. This guide will walk you through each section of the form to ensure that you complete it accurately and in accordance with the required guidelines.

Follow the steps to complete the Affidavit Form online.

1. Press the ‘Get Form’ button to obtain the affidavit form and open it in your preferred editor.
2. Begin by entering your full name in the designated section, including your first name, middle initial, and last name.
3. In the following section, confirm your understanding of the two-year opt-out period, acknowledging that you will submit a new affidavit if you wish to continue opting out after this period.
4. Specify that you will provide services only through private contracts during the opt-out period and that you will not submit claims to Medicare except where emergency services are involved.
5. Complete the identification section, ensuring to include your Medicare PTAN if assigned or the necessary information to opt-out if not enrolled.
6. Fill out your professional details, including your address, city, state, zip code, telephone number, specialty, NPI, Social Security number, date of birth, school information, year of graduation, and email address.
7. Attach a copy of your applicable licensure as requested in the form.
8. Review all sections to ensure accuracy and completeness before signing and dating the affidavit.
9. Once completed, save your changes. You have the option to download, print, or share the form as needed. Finally, mail the form to Palmetto GBA at the specified addresses.

Complete your Affidavit Form - Palmetto GBA online today to ensure your opt-out status is officially recognized.