Medicare Private Contract Form
Are you on Medicare? That's ok, we can still take care of you.
Our physicians have "opted-out" of Medicare. In order for them to provide you service, we ask that you sign a private contract.
Section 4507 of the 1997 Balanced Budget Act allows a physician to enter a private contract with a Medicare beneficiary. We, Preferred Family Medicine, will retain the contract for the duration of his opt-out period (renews every 2 years). We will supply Medicare with a copy of this contract upon request. The private contract remains in effect for two years.
Click on the button below to link to the contract form. You may fill this out prior to your appointment, or at your first appointment.
Request Medical Records FROM Another Provider TO Preferred Family Medicine
Do you need your medical records sent from another facility to Preferred Family Medicine?
We may need you to authorize us to access your Personal Health Information (PHI). Some scenarios are listed below:
- You are a new patient to Preferred Family Medicine
- You have been to another facility, such as the hospital, a lab, or an imaging center
- You have been to a specialist/consultant
- You are a representative of a patient and need to access their personal health information
Download the form by clicking on the button below. Print, fill out and either send it to us or take it take it to the provider.
Of course, you may contact the provider yourself if you'd rather do it on your own. If so, you may either get a digital copy of your records (like a thumb drive), have them fax to us at 775-501-6360, or send the records digitally in CCD format.