Medicare Consent

NOTICE TO PATIENTS IN ADVANCE OF SERVICES THAT WILL NOT BE COVERED BY MEDICARE

Medicare will only pay for services that it determines to be "reasonable and necessary" under section 1862(a) of the Medicare Law. Medicare will not reimburse for (1)acupuncture, (2)chelation, (3)IV drips, (4) Other , for the following reasons given by Medicare:

"Not reasonable and necessary" or

"Services not covered"

By my signature below I confirm that in advance of the provision of the services listed above I informed the patient fully of my reasons for believing that Medicare will deny payment for those services and that I have provided the patient with a copy of this document for his/her review and signature.

__________________________ Date:__________
Sharda Sharma, MD

BENEFICIARY AGREEMENT:
I have been notified by my doctor that she believes that I will not be reimbursed by Medicare for the service(s) identified above, for the reason(s) stated. I agree to be personally and fully responsible for payment.

Beneficiary's Name:
Beneficiary's Signature:____________________________ Date:____________

NOTE: You will have an opportunity to sign this form during your next visit.