CMS Pub. 100-04, ch. 1, § 30.3.12.2

MEDICARE

PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT

Name(s) and Address of Participant* National Provider Identifier (NPI)*

*List all names and the NPI under which the participant files claims with the Medicare

Administrative Contractor (MAC)/carrier with whom this agreement is being filed.

The above named person or organization, called “the participant,” hereby enters into an

agreement with the Medicare program to accept assignment of the Medicare Part B

payment for all services for which the participant is eligible to accept assignment under

the Medicare law and regulations and which are furnished while this agreement is in

effect.

1. Meaning of Assignment - For purposes of this agreement, accepting assignment of

the Medicare Part B payment means requesting direct Part B payment from the Medicare

program. Under an assignment, the approved charge, determined by the MAC/carrier,

shall be the full charge for the service covered under Part B. The participant shall not

collect from the beneficiary or other person or organization for covered services more

than the applicable deductible and coinsurance.

2. Effective Date - If the participant files the agreement with any MAC/carrier during the

enrollment period, the agreement becomes effective _____________________.

3. Term and Termination of Agreement - This agreement shall continue in effect

through December 31 following the date the agreement becomes effective and shall be

renewed automatically for each 12-month period January 1 through December 31

thereafter unless one of the following occurs:

a. During the enrollment period provided near the end of any calendar year, the

participant notifies in writing every MAC/carrier with whom the participant has

filed the agreement or a copy of the agreement that the participant wishes to

terminate the agreement at the end of the current term. In the event such

notification is mailed or delivered during the enrollment period provided near the

end of any calendar year, the agreement shall end on December 31 of that year.

b. The Centers for Medicare & Medicaid Services may find, after notice to and

opportunity for a hearing for the participant, that the participant has substantially

failed to comply with the agreement. In the event such a finding is made, the

Centers for Medicare & Medicaid Services will notify the participant in writing

that the agreement will be terminated at a time designated in the notice. Civil and

criminal penalties may also be imposed for violation of the agreement.

__________________________

Signature of participant

_________________________

Title

_________

Date