Medicaid Opt-Out Form

I, or my legal representative, understand that plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;

I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

Today's Date:

Client's Name:

Client's Date of Birth:

Client's Phone Number:

Client's Mailing Address:

By signing this form, I certify:

• That I have read or had the Medicare Opt-Out form read to me and had the Medicare Opt-Out form explained to me.

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Client's Signature:

If any person assisted the client in completing this form, please include their 

NAME:

RELATIONSHIP TO CLIENT: 

CONTACT INFORMATION: