Affidavit Physician Withdrawal Form
Description
Form popularity
FAQ
Physicians and practitioners who do not wish to enroll in the Medicare program may opt-out of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare.
Call 1-800-772-1213. TTY users can call 1-800-325-0778. Contact your local Social Security office.
To opt out, you will need to: Submit an opt-out affidavit to Medicare. Enter into a private contract with each of your Medicare patients.
In order to opt out you must file an opt-out affidavit with the Medicare Administrative Contractor (MAC) or Carrier that administers any jurisdiction you practice in. A template for this affidavit that conforms to Medicare rules follows.
In order to opt out you must file an opt-out affidavit with the Medicare Administrative Contractor (MAC) or Carrier that administers any jurisdiction you practice in. A template for this affidavit that conforms to Medicare rules follows.
