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Get Center for Hope and Healing Medicare Opt-Out Affidavit 2011-2024

____ (Therapist), being duly sworn, depose and say: 1. I promise that, except for emergency or urgent care services (as specified in 42 C.F.R. §405.440), during the opt-out period I will provide services to Medicare beneficiaries only through private contracts that meet the criteria of 42 C.F.R. §405.415 for services that, but for their provision under a private contract, would have been Medicare-covered services. 2. I promise that I will not submit any claim to Medicare for any item or servic.

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