Gulrukh Rizvi MD LLC – Member Agreement
This is an Agreement entered into on (date) by and between Gulrukh Rizvi MD LLC, located at 1161 Lincoln Street, Eugene OR 97401, and you (Principal and Patient Member). Gulrukh Rizvi M.D. (Physician) serves in the capacity as an agent of Gulrukh Rizvi MD LLC.
Principal Member (financially responsible party):
Primary Mailing Address: _______________________________
Phone Number: _______________________________
- This is a Direct Primary Care practice and not health insurance. No insurance is allowed to be billed, including third party payors, for the medical services provided by Gulrukh Rizvi MD LLC.
- The practice provides only the Services in this Agreement as outlined in paragraphs 3 and 4. Services include: wellness and preventative office visits, treatment of immediate and long-term medical conditions, minor surgery, coordination of care, direct cell phone and email access to the physician, access to wholesale medications, and discounted lab and imaging work. All services not included in this Agreement are the patient’s responsibility.
- Termination and Refund Policy. The Agreement renews monthly. If this Agreement is terminated by either party before the Agreement termination date, then Gulrukh Rizvi MD LLC shall refund, within 30 days of termination notice, the Principal Member’s share of the payment for any advance Membership fees extending past the end of the calendar month of termination notice, minus the costs of any additional fees due as outlined in paragraph 8.
- Enrollment and Monthly Membership Fee. For new Memberships, a one-time non-refundable enrollment fee of $215 will be charged. For previous Principal or Patient Members of Gulrukh Rizvi MD LLC, whose Membership has been terminated and who would like to re-enroll, a one-time non-refundable re-enrollment fee of $300 will be charged. The Principal Member shall then pay a recurring monthly Membership fee of $95 per adult Patient Member, $45 per child Patient Member (17 years old or younger during the month Services are provided) if in addition to an adult Patient Member, or $75 per child Patient Member if not in addition to an adult Patient Member, billed on the first day of each month. The first month’s Membership fee will be prorated to reflect the Membership beginning on the date a new Patient Member first utilizes Gulrukh Rizvi MD LLC’s Services. The monthly Membership shall be automatically renewed until either party receives notice of Membership termination. Additional fees for laboratory and imaging work or travel time for home calls may also be incurred, as outlined in paragraph 8.
- The Department of Consumer and Business Services has issued a certification to this practice. You can contact consumer advocates at the Department of Consumer and Business Services at (888)977-4894, email@example.com or http://www.insurance.oregon.gov
1. Background. The Physician, who specializes in Family Medicine, delivers care on behalf of Gulrukh Rizvi MD LLC, at the address set forth above. In exchange for certain fees paid by the Principal Member, Gulrukh Rizvi MD LLC through its Physician, agrees to provide Patient Members with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
- 2. Definitions:
- Patient Member. Defined as those persons for whom the Physician shall provide Services, and who are signatories to, or listed above as Patient Members, and incorporated by reference, to this agreement.
- Principal Member. Defined as the persons who are financially responsible for enrollment and membership fees. The Principal Member may or may not also be a Patient Member.
- Membership. Gulrukh Rizvi MD LLC is a physician owned and managed medical practice. Membership is defined as eligibility for medical services and non-medical services as outlined in paragraphs 3 and 4.
- Physician. A Physician is an independent contractor. Gulrukh Rizvi MD LLC provides services through its Physician, Gulrukh Rizvi M.D.
- Services. As used in this Agreement, the term Services, shall mean a package of both medical and non-medical services provided by Gulrukh Rizvi MD LLC, as defined under paragraphs 3 and 4, that are included in the price of membership.
- Medical Services: Gulrukh Rizvi MD LLC shall provide office-based medical Services to the Patient Members listed on page 1 of this Agreement (in accordance with the limitations of paragraph 5 below).
- Wellness and preventive office visits, which are visits for the preservation of physical and mental wellness, healthy lifestyle counseling, discussion of preventive guidelines, nutrition and exercise, and sports physicals.
- Treatment of immediate problems, including but not limited to: sore throats, coughs, colds, IUD placement, Nexplanon placement, respiratory infections, sexually transmitted infections, sinus infections, sprains, strains, warts, skin tags, skin biopsies, and minor injuries.
- Management of long-term medical conditions including but not limited to, allergies, anxiety, asthma, back pain, congestive heart failure, chronic diarrhea, depression, diabetes, digestive problems including IBS, Celiac disease, food intolerances, gout, headaches, migraines, heartburn/GERD, high blood pressure, high cholesterol, insomnia, leg swelling, menopausal and peri-menopausal management, prostate problems, sexual problems, thyroid problems, ulcers, and weight management.
- Minor surgery including but not limited to: cyst draining/removal, suturing, laceration repair, and nail removal.
- Care coordination to assist other health team members by organizing and forwarding pertinent information from primary exams for use by specialists.
- Non-Medical Services. Gulrukh Rizvi MD LLC shall also provide Patient Member with the following Non- Medical services (“Non-Medical Services”):
- Continuous Access: Patient Member shall have access to the Physician via direct telephone and email and on a continuous basis as best possible. During routine visits Patient Members will receive training on how best to communicate needs with the Physician, such that non-urgent needs are communicated during business hours and urgent needs are directly called whenever necessary. In the event that the Physician is off duty due to illness, vacation, or unforeseen emergency, Gulrukh Rizvi MD LLC will provide the services of an appropriate licensed healthcare provider for assistance in obtaining medical services. Patient shall be given instructions as to how to contact the covering healthcare provider. Such a provider shall be available to Patient to the same extent as would the Physician, however provider shall be contacted through an answering service rather than through a direct phone line through
which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member of Gulrukh Rizvi MD LLC in a timely manner. Patient Member understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient Member could reasonably expect may develop into an emergency. Patient Member agrees that in such situations when they cannot speak to Physician immediately in person or by telephone that they shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.
- No Wait or Minimal Wait Appointments: Every effort shall be made to assure that Patient Member is seen by the Physician immediately upon arriving for a scheduled office visit or after only a minimal wait. If Physician foresees a minimal wait time, Patient shall be contacted and advised of the projected wait time.
- Same Day/Next Day Appointments: When Patient Member calls or emails the Physician prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with the Physician on the same day if necessary. If the patient calls or emails the Physician after noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule Patient’s appointment with the Physician on the following normal office day.
- Email Access: Patient Member shall be given the Physician’s email address
- Home Visits: Home visits within a 10 minute drive may be made on a limited basis at the discretion of the Physician. Travel time beyond 10 minutes will be charged at a rate of $120 for 30 minutes and will be rounded up to the nearest 30-minute interval.
- Coordinating Care with Specialists: Gulrukh Rizvi MD LLC Physician shall coordinate as needed with medical specialists to whom Patient Member is referred to assist Patient Member in obtaining specialty care. Patient Member understands that fees paid under this Agreement do not include and do not cover specialists’ fees or fees due to any medical professional other than Gulrukh Rizvi MD.
- Wholesale Medications, Radiology and Laboratory Discounts: Every effort will be made to procure wholesale discounted medications, labs and imaging for Patient Members. Gulrukh Rizvi MD LLC will charge any shipping fees +10% of the cost of medications in addition to the wholesale price of medications to cover cost of managing medication dispensing.
- Services Excluded. Membership in Gulrukh Rizvi MD LLC does not include immunizations, medical devices, emergency medical services, hospital care, radiology, or other specialty healthcare needs. Referrals may be made for these services when necessary. All services not included in this Agreement are the patient’s responsibility.
- Urgent Medical Care. The Physician will strive to return the majority of calls within 4 hours, unless the Physician is otherwise occupied. After a telephone consultation with the Patient Member, the Physician will determine, within his/her sole discretion, whether the illness or medical condition requires same-day physician care. If same-day physician care is warranted, arrangements will be discussed with the Patient Member to determine whether an office visit, phone visit, Urgent Care or Emergency Room visit is most appropriate. If same-day care is not warranted in the Physician’s discretion, the Patient Member shall be scheduled for an appointment on the next calendar day which is not a weekend day or holiday as soon as possible. Urgent weekend or after-hours calls are not recommended and patients should contact an emergency room or call 911 if immediate medical attention is needed.
- Physician Absence. The Physician may from time to time, due to vacations, sick days, and other similar situations, not be available to provide Services. Every effort will be made to notify patients of these times in advance. During such times, Patient Member calls to the Physician will be routed to a message indicating absence from duty and what time full service is expected to resume. Every effort will be made to arrange for another physician to be “covering” if the primary Physician is unavailable. There will be no additional costs to the Principal Member if a covering physician provides Services while the primary Physician is unavailable. If a Patient Member has a concern which is urgent and the Physician is absent from duty, they should proceed to the nearest urgent or emergency care facility or call 911.
- Fees. Gulrukh Rizvi MD LLC will not bill or be responsible to submit or collect any health insurance benefits for any services rendered under the Membership. The Principal Member shall be responsible for the following costs:
- Enrollment and Monthly Membership Fee: For new Memberships, a one-time non-refundable enrollment fee of $215 will be charged. For previous Principal or Patient Members of Gulrukh Rizvi MD LLC, whose Membership has been terminated and who would like to re-enroll, a one-time non-refundable re-enrollment fee of $300 will be charged. The Principal Member shall then pay a recurring monthly Membership fee of $95 per adult Patient Member, $45 per child Patient Member (17 years old or younger during the month Services are provided) if in addition to an adult Patient Member, or $75 per child Patient Member if not in addition to an adult Patient Member, billed on the first day of each month. The first month’s Membership fee will be prorated to reflect the Membership beginning on the date a new Patient Member first utilizes Gulrukh Rizvi MD LLC’s Services. The monthly Membership shall be automatically renewed until either party receives notice of Membership termination.
- Any laboratory studies, on-site lab drawing, medical supplies, imaging studies or medications will be billed at the time of ordering/service directly to the Principal Member either from Gulrukh Rizvi MD LLC or the lab/service provider in addition to the monthly membership fee. Pricing for supplies and medications provided by Gulrukh Rizvi MD LLC will be at cost, any shipping, +10% charge to cover cost of management.
- Transit Fee. Applies to any home visits beyond a 10 minute drive from the clinic. Travel time beyond 10 minutes will be charged at a rate of $120 for 30 minutes and will be rounded up to the nearest 30-minute interval.
- Payment. Preferred method of payment is recurring monthly automatic bank withdrawal or credit card charge. The Principal Member shall pay to Gulrukh Rizvi MD LLC a monthly Membership Fee which shall be charged via the preferred method of payment. The monthly Membership fee shall be automatically charged from the credit card or bank account on the first day of each month, beginning the first full month after your first visit. If the Principal Member begins their membership in the middle of the month, the first payment will be prorated to reflect the Membership beginning on the date a new Patient Member first utilizes Gulrukh Rizvi MD LLC’s Services, and then full monthly Membership payments will begin the following month. Payment for additional Services including but not limited to lab work, medications or procedures, are billed to the Principal Member at the time of service via credit or debit card transaction only. Monthly check payments are not accepted. Coverage will be lost if payment is not received by the 10th of the month. Late payments will be charged an additional $20 fee.
- Terms. This Agreement shall commence on the date signed by the parties below and shall continue for a period of one month, automatically renewed. The Agreement will be reviewed and re-signed annually.
- Non-Participation in Insurance. Patient Member acknowledges that neither Gulrukh Rizvi MD LLC, nor the Physician participate in any health insurance or HMO plans or panels and has opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third party payment plans applicable to the Patient or Principal Member. The Patient Member shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the agreement attached as Appendix 1, and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any Services performed for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such Services. Patient shall renew and sign the agreement in Appendix 1 yearly.
- Insurance or Other Medical Coverage. Principal and Patient Members acknowledge and understand that this Agreement is not an insurance plan, and is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). Membership in Gulrukh Rizvi MD LLC will not cover hospital services, or any services not personally provided by Gulrukh Rizvi MD. Patient Member acknowledges that Gulrukh Rizvi MD LLC has advised that Patient Member obtain or keep in full force such health insurance policies or plans that will cover Patient Member for general healthcare costs. Principal and Patient Members acknowledge that this Agreement is not an Agreement that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient Member may carry.
- Consumer Rights. Patient and Principal Members should be aware that the Department of Consumer and Business Services issued a certification to this practice. You can contact consumer advocates at the Department of Consumer and Business Services at (888) 977-4894, firstname.lastname@example.org, or http://www.insurance.oregon.gov.
- Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, Principal or Patient Members and Gulrukh Rizvi MD LLC shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving written notice to the other party. Unless previously terminated as set forth above, the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the beginning of the Agreement month. Upon termination of the Agreement, Principal/Patient Member will not be eligible for future “one-time” visits. If re-enrollment is requested after a Membership has been terminated, there will be a re-enrollment fee of $300.
- Refunds. If termination is requested by the Principal Member, a Patient Member, or Gulrukh Rizvi MD LLC, it will become effective at the end of that calendar month. Any prepaid Membership fees billed for future months will be reimbursed within 30 days of notice of termination, minus the costs of any additional fees due as outlined in paragraph 8. For example, if notice of termination is provided on June 14th, any fees paid for service for July 1st onwards will be reimbursed by July 14th. Upon notice of termination, Patient Member will be terminated from the Membership benefit.
- Cancelled or Missed Appointments. Principal Member shall be charged $20 if a Patient Member cancels his or her appointment within 24 hours of the scheduled appointment or otherwise fails to attend the scheduled appointment unless there is an emergency or the patient is too ill to attend the appointment. Three unexplained no-shows in the span of one year will result in termination of Membership.
- Communications. Patient Member acknowledges that communications with the Physician using email, facsimile, instant messaging, and telephone are not guaranteed to be secure or confidential methods of communication. As such, the Patient Member expressly waives the Physician’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical record. By providing an email address, Patient Member authorizes Gulrukh Rizvi MD LLC, and its Physicians to communicate with Patient Member by email regarding their “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations). Patient Member acknowledges that:
- Although the Physician will make all reasonable efforts to keep email communications confidential and secure, neither Gulrukh Rizvi MD LLC, nor the Physician can assure or guarantee the absolute confidentiality of email communications.
- E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access.
- Email communications may be made a part of Patient Member’s permanent medical record.
- Patient Member understands and agrees that email is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information.
- Unless written otherwise, you have provided permission to leave voicemails with personal health information at the contact phone you have provided with lab results/personal health information.
In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, Patient Member shall call 911 or the nearest emergency room, and follow the directions of emergency personnel.
If Patient Member does not receive a response to an email message within one day, Patient Member agrees to use another means of communication to contact the Physician. Neither Gulrukh Rizvi MD LLC, nor the Physician will be liable to Patient Member for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient Member as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address email messages, (iii) failure of the Gulrukh Rizvi MD LLC’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of email communications by a third party; or (v) Patient Member’s failure to comply with the guidelines regarding use of email communications set forth in this paragraph.
- 18. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such by federal, state, or local law or regulation (“Applicable Law”), and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within 45 days after the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
- 19. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
- 20. Reimbursement for Services Rendered. Gulrukh Rizvi MD LLC does not provide refund or reimbursement for any Services rendered by Gulrukh Rizvi MD LLC. If this Agreement is held to be invalid for any reason, and if Gulrukh Rizvi MD LLC is therefore required to refund all or any portion of the monthly fees paid by Principal Member, Principal Member agrees to pay Gulrukh Rizvi MD LLC an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
- 21. Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Gulrukh Rizvi MD LLC may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending Principal and Patient Members 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Gulrukh Rizvi MD LLC, except that Patient Member shall initial any such change at Gulrukh Rizvi MD LLC’s request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
- 22. Assignment. This Agreement, and any rights Principal or Patient Member may have under it, may not be assigned or transferred by Principal or Patient Member.
- 23. Relationship of Parties. Patient Member and the Physician intend and agree that the Physician, in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physician shall have exclusive control of his work and the manner in which it is performed.
- 24. Legal Significance. Patient Member acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient Member also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
- 25. Notices. All notices and information relating to this Agreement and Plan shall be provided in writing and delivered to the mailing address of the Principal/Patient Members indicated on page 1 of this Agreement or, if to Gulrukh Rizvi MD LLC, delivered to the address provided below: Gulrukh Rizvi MD LLC, 1161 Lincoln Street, Eugene, OR 97401. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.
- 26. Applicability. This Agreement is intended solely for the benefit of the Principal Member and Patient Members whose names are indicated on this Agreement. Gulrukh Rizvi MD LLC reserves the right to exclude any individual from participation in Membership if Physician has determined the relationship to be dangerous or not medically therapeutic. All Principal and Patient Members shall sign this Agreement, thereby consenting to and agreeing to all of the terms and conditions of this Agreement. A parent or guardian shall sign on behalf of all minors or incapacitated parties who are under this Agreement. All parents or guardians of minors or incapacitated persons who are listed as Patient Members, further agree to be financially responsible for all cost and services provided to such minor and/or incapacitated person.
- 27. Counterparts. To respect the privacy of each Patient Member, this Agreement may be executed with multiple copies of Page 9, each of which shall indicate the signature of a separate adult Patient Member, and all of which shall be deemed to be integral parts of this Agreement.
- 28. Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
- 29. Entire Agreement. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
- 30. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Oregon and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Gulrukh Rizvi MD LLC’s address in Eugene, Oregon.
- 31. HIPAA Acknowledgement and Consent. Patient Member acknowledges that he/she has been provided with the Notice of Privacy Practices of Gulrukh Rizvi MD LLC either in electronic or paper form, that he/she has been given ample time to read and study it, and that he/she has been given the opportunity to ask questions regarding its content.
Consent for Medical Treatment and Policies
- I voluntarily consent to medical treatment and diagnostic procedures provided by Gulrukh Rizvi MD LLC.
- I consent to the testing for infectious and other diseases as deemed advisable by my Physician.
- I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made as to the result of treatments, testing or examinations.
- I agree that all information I convey is accurate.
- I understand that the physicians in the clinic office building are not partners or otherwise affiliated with respect to the medical services provided by them. They are independent practitioners and simply share office space and equipment in their separate practices. They are not responsible for each other’s practices or patients. From time to time, one of the physicians may provide services to the other physician’s patients in an on-call situation (i.e., when the other physician is unavailable). In such events, the patient will be deemed the patient of the providing/on-call physician only to the extent of the specific services provided by the providing/on-call physician. There will be no additional charges or costs to the Principal Member during these on-call situations.
- I acknowledge I have read and agree to abide by the policies above.
The parties have signed duplicate counterparts of this Agreement on the date first written above.
Signed & Dated,
Print: _____________________________________________ Date of Birth: ___/___/___
Sign: _____________________________________________ Date: __________
Patient Member(s) (if different than the above Principal Member):
1) Print: _____________________________________________ DOB.: ___/___/___
Sign: _____________________________________________Date: __________
2) Print: _____________________________________________ DOB.: ___/___/___
Sign: _____________________________________________Date: __________
3) Print: _____________________________________________ DOB.: ___/___/___
Sign: _____________________________________________Date: __________
4) Print: _____________________________________________ DOB.: ___/___/___
Sign: _____________________________________________Date: __________
5) Print: _____________________________________________ DOB.: ___/___/___
Sign: _____________________________________________Date: __________
Founder, Gulrukh Rizvi MD LLC:
Print: __Gulrukh Rizvi, M.D.__________________________
Sign: _____________________________________________ Date: __________
Appendix 1: Medicare Opt-Out Agreement
Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary. Enter the provider’s name and the beneficiary’s name in the appropriate boxes. Signatures from the provider, a witness and the patient/beneficiary or their legal representative are required below.The supplier must submit an affidavit to Medicare expressing his/her decision to opt-out.
I, (the Medicare beneficiary) have not been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act 1043278468.
I (the Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services furnished by Dr. Gulrukh Rizvi.
I (the Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to what Dr. Gulrukh Rizvi may charge for items or services furnished.
I (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Dr. Gulrukh Rizvi to submit a claim to Medicare.
I (the Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any items or services furnished by Dr. Gulrukh Rizvi that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
I (the Medicare beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
The expected or known effective date and expected or known expiration date of the opt- out period is January 1, 2017 (effective date) and December 31, 2019 (expiration date).
I (the Medicare beneficiary) or my legal representative understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
This contract cannot be entered into by me, (the Medicare beneficiary), or by my legal representative during a time when I, (the Medicare beneficiary), require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual)
I (the Medicare beneficiary) or my legal representative will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract.
I, Dr. Gulrukh Rizvi will retain the original contract (original signatures of both parties required) for the duration of the opt-out period.
I, Dr. Gulrukh Rizvi will supply CMS with a copy of this contract upon request.
I, Dr. Gulrukh Rizvi understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers.
Patient’s Legal Representative Signature:
_____________________________________________ Phone #:_________________