MEDICARE ACKNOWLEDGEMENT AND HMO DECLARATION

Under section (a)(1) of the federal Medicare Law, “Medicare will only pay for services that is determined to be reasonable and necessary.”

If Medicare determines that a particular service is not reasonable and necessary, or simply does not cover that service in any instance, Medicare may deny payment for that service. Possible reasons given by Medicare for denial of reimbursement due to their determination or the lack of medical necessity are available for your review and will be discussed with you if we feel they will apply in your case. 

Effective, January 1,1988, Federal Legislation allows Medicare beneficiaries to enroll in a Health Maintenance Organization (HMO). By enrolling in an HMO, you are subject to HMO’s regulations, rather than to Medicare regulations. If you are enrolled in an HMO, there is a possibility that you will not receive vision care benefits through our office. 

In this case you would be responsible for the services rendered. 

BENEFICIARY AGREEMENT: I agree to be personally responsible for full payment for services, in the event that Medicare denies payment for any reason.