Get Medicare Opt Out Letter

Filling out the Medicare Opt Out Letter is an essential step for healthcare providers who wish to opt out of Medicare. This guide provides clear, step-by-step instructions to help you navigate the online form with ease.

Follow the steps to complete the Medicare Opt Out Letter online

1. Click ‘Get Form’ button to obtain the Medicare Opt Out Letter and open it in the editor.
2. Begin by entering your full name in the designated field. This should match the name as it appears on your professional credentials.
3. Indicate the date you are filling out the letter in the provided date field.
4. In the following section, confirm your commitment to provide services to Medicare beneficiaries only through private contracts during the opt-out period, except for emergency services, as outlined in the Medicare guidelines.
5. Acknowledge that you will not submit any claims to Medicare for services provided to Medicare beneficiaries during the opt-out period. This includes claims submitted by any entities acting on your behalf.
6. Read and confirm your understanding that during the opt-out period, no direct or indirect Medicare payments will be received for services rendered to beneficiaries.
7. Provide the minimum information required, including your legal business name, principal office address (ensure it’s not a P.O. Box), telephone number, and Medicare Provider Transaction Access Number (PTAN) if applicable.
8. Fill in your Tax Identification Number (TIN) or Social Security Number (SSN), as well as your medical specialty.
9. If you intend to continue ordering or referring services for Medicare beneficiaries post-opt out, include your date of birth and National Provider Identifier (NPI).
10. Sign the completed affidavit in the designated signature field to validate the information provided.
11. Review the entire document for accuracy before finalizing it.
12. Once completed, save the changes, download the document, or print it for mailing to the appropriate National Government Services address based on your location.

Take the next step in managing your Medicare status by completing the Medicare Opt Out Letter online today.