1. Hilltop Medical Clinic/Hilltop Medical Clinic West is a NON-Participating Provider for Medicare.We have a provider number with Medicare for them to process the claim and pay directly to you.
2. We are payment at the time of service. We do NOT Accept Assignment (Medicare payment) on Medicare claims.
3. Medicare will consider reimbursement on the Physician, Xray and some injection charges.We are notifying you that Medicare will NOT reimburse you for the following services (nor will Hilltop Medical Clinic/ Hilltop Medical Clinic West) an by signing this you understand you will owe for the following services:
- Laboratory text performed in our office that get applied toward your deductible.
- Handling charges on laboratory test sent to an outside lab.
- Various allergy or hormone injections or immunizations (tetanus).
- General Physical exams and the corresponding test, including TB tines or PPD tests.
- All medical supplies (i.e. Orthopedic, suture tray, dressing, etc.).
- Oral prescription drugs purchased form our clinic.
4. At this time, we are unaware of any other services we provide which are determined by Medicare to be not covered because they are not reasonable and necessary for treatment of illness or injury.
5. My signature below authorizes Hilltop Medical Clinic/ Hilltop Medical Clinic West to release medical information about me to the CMS Centers for Medicare & Medicaid Services and its agents to determine these benefits payable to related services. I understand my signature requests that payment be made to me and authorizes release of medical information necessary to process this claim.
6. Hilltop Medical Clinic / Hilltop Medical Clinic West is required by law to submit your Medicare claims to Palmetto G.B.A. Medicare is to respond directly to you. Please do not submit your own claims to Medicare. Allow 30-45 days before following up with Medicare on an unpaid claim.
7. Medicare forwards your claims to your supplemental insurance company. Hilltop Medical Clinic/Hilltop Medical Clinic does not receive and EOMB Explanation of Medical Benefits from Medicare. Please contact Medicare with your supplemental insurance information if you have not done so.
8. I understand that Hilltop Medical Clinic/ Hilltop Medical Clinic West does not accept MEDI-CAL/MEDICARE patients. I do not have MEDI-CAL as a primary OR a supplemental to Medicare.
I have been informed of Hilltop Medical Clinic / Hilltop Medical Clinic West’s policy in regards to me, the Medicare patient. The entire bill will be strictly my responsibility to pay today.
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SIGNATURE OF PATIENT/LEGAL GUARDIAN — DATE
