Medicare Coverage Office Visits: Medicare is a Federal program for the elderly and disabled associated with Social Security. For persons with Part B coverage, Medicare covers 80% of the reasonable charges for office visits subject to a $100 deductible which begins January 1 of each year. When the patient has two insurances, Medicare is always primary except for auto accidents or when the patient or patient¼s spouse is employed and receives group health insurance benefits through the employer. Medicare patients have the option of purchasing HMO coverage with their Part B benefits. If they choose this option, chiropractic care will no longer be covered. Medicare Card Medicare patients will have a white paper card with a red and blue stripe. Important parts of the card are numbered and explanations are given below: 1. BENEFICIARY: This is the name of the patient. Each Medicare recipient will have his/her own card. 2. CLAIM NUMBER: This number is the patient¼s Medicare number. It is the Social Security number of the person who contributed to Social Security along with an alpha suffix. 3. HOSPITAL INSURANCE: This is Medicare Part A. It is automatically included for any Medicare recipient. It covers hospitalization charges. 4. MEDICAL INSURANCE: This is Medicare Part B. One-Time Authorization I request payment of authorized Medicare benefits be made either to me or on my behalf to this clinic for any services furnished me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. ______________________________ _____________________ Signature of Patient Date Medicare Waiver of Liability Medicare will only pay for services that it determines to be „reasonable and necessary¾ under section 1862(a) of Title XVIII of the Social Security Act. If Medicare determines that a particular service is not reasonable and necessary under Medicare program standards, Medicare will deny payment for that service. I believe that, in your case, Medicare is likely to deny payment for _____________________________________________ for the following reasons: [ ] 1. Medicare usually does not pay for this many services in this time period. [ ] 2. Medicare may not pay for this service for the diagnoses indicated. Plan of Treatment: I will see this patient _______ a week on an as-needed basis from ________ to _______. Date Date I have been notified by my physician that he or she believes that in my case Medicare is likely to deny payment for the services identified above for the reasons stated. If Medicare denies payment, I agree to be fully and personally responsible for payment. __________________________________ _________________ Signature of Patient Date