Physician Notice and Beneficiary Agreement
The Physicians at Aspire Osteopathic Wellness are not designated Medicare providers.
As a result, no services provided are covered under Medicare part B.
I have been notified by my physician that services provided are not eligible for Medicare
coverage. I understand that this limitation also applies to all secondary insurance
By entering and signing this contract, I understand:
1. Agree not to submit a claim or to request the physician to submit a claim for
payment under Medicare, even if Medicare would otherwise cover such items and
2. Acknowledge that Medical plans do not, and that other supplemental insurance
plans may choose not to, make payment for items and services furnished by the
doctors under the contract.
3. Agree to be responsible for payment of such items or services.
4. Acknowledge that Medicare will provide no reimbursement for such items and
5. Acknowledge that the doctors are not limited in the amount that they may
charge the beneficiary for the items and services furnished.
6. Acknowledge and agree that the Medicare beneficiary is not seeking the
doctor’s help during a time of medical emergency or urgent health care situation.