Get 13 Chenell Drive, Suite 2, Concord, Nh 03301

This guide provides comprehensive steps for successfully completing the Medicare private contract form from 13 Chenell Drive, Suite 2, Concord, NH 03301. By following these instructions, users can navigate the form easily and ensure that all necessary information is accurately entered.

Follow the steps to complete the Medicare private contract form online.

1. Press the ‘Get Form’ button to access the Medicare private contract form and open it in your preferred online editor.
2. In the first blank section, indicate the day of the month when the contract is being entered into. For example, write '15' if it is the fifteenth day.
3. In the next blank, write down the full name of the patient who is enrolled in Medicare Part B.
4. Fill out the patient's residential address in the following section, ensuring to include the street address, city, state, and ZIP code.
5. Review the background information provided to understand the purpose of the private contract, as this will help clarify the responsibilities of both parties.
6. In section A regarding the obligations of the physician, no action is required; this is informational. However, be familiar with these obligations as they pertain to the physician's duties.
7. In section B, review the obligations of the patient. Make sure the patient acknowledges each point as they signify understanding of the agreement.
8. In section C, indicate whether the physician has been excluded from participation in the Medicare program by checking the appropriate option.
9. For the term and termination section, note the commencement date as '12/31/2017' and leave the subsequent blank for the end date, which should be two years later.
10. Both the physician and patient should print their names in the designated fields and sign the contract on the lines provided.
11. Enter the dates of each signature in the fields provided to complete the form.
12. Once all information is accurately entered, you can save changes, download, print, or share the completed form as needed.

Complete your Medicare private contract form online today to ensure an efficient and hassle-free experience.