I understand that as part of my healthcare Lipedema Surgery Center will need to contact me from time to time. I hereby authorize you to contact me in the following ways and leave messages at the following numbers:
If you would like us to be able to discuss your healthcare with anyone (i.e. family member), please list:
The undersigned authorizes treatment and procedures performed by the physician and employees of the center and understand that no guarantee is made as to the results that may be obtained. All professional services rendered are charged to the patient. The PATIENT is responsible and agrees to pay for all services. The patient understands that Dr. Byrd has opted out of Medicare and Medicare will not reimburse for any charges incurred in our office. I authorize the release of all of my medical records for the purpose of treatment, payment, and health-care operations. I acknowledge that HIPAA privacy practices are available to me at my request.
Do you have any of the following symptoms:
Our office is not in network with any insurance companies, but we will assist in preparing your documents and getting it pre-approved. We will also appeal any denied claims on your behalf. Payment for surgery is required up front if your insurance company does not allow for Single Case Agreements (SCA). Any reimbursement from the insurance company goes directly to you. Sometimes the insurance companies want to set up a peer-to-peer review with Dr. Byrd to discuss the case and she is happy to do that. If there is anything you need, please do not hesitate to contact us.
The first step is to complete the packet and have a consultation with Dr. Byrd to see if you are a candidate for surgery. We will need to see you in person to prepare the necessary documents for your insurance company. There is a $200.00 charge for the office visit.
Our office has opted out of Medicare. All patients are required to sign the Opt Out Medicare Waiver. Neither our office, nor the patient can send any documents into Medicare or Medicaid for any procedures done here in our office.
Procedure codes used: 15879-22,50 15878-22,50 15877-22
Diagnostic codes are: I89.0, M79.609, R20.8 and R26.9
I understand that Dr. Byrd has opted out of Medicare and Tricare and I am unable to use Medicare and/or Tricare in this office for any procedures or visits.
Consultations are $200.00. We will take a non-refundable $50.00 deposit to book the appointment and the remaining $150.00 will be due the day of the consultation. Our surgery coordinator will contact you once you have returned the completed paperwork to schedule the appointment.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule.
A Copy of this law and policy is available to you upon request.
The Doctor and Staff at Lipedema Surgery Center have my permission to release my medical and personal information to:
List Names and Relationship of who you would like your information shared with:
ALL PATIENTS MUST SIGN to acknowledge that Dr. Byrd has opted out of Medicare
***MEDICARE PRIVATE CONTRACT IN COMPLIANCE WITH 42 U.S.C. §1395a; 42 C.F.R. § 405, SUBPART D
This contract is entered into by and between Marcia V Byrd, MD (hereinafter called “physician”), whose principal medical office is located at 11050 Crabapple Road Roswell, GA 30075 and
The physician acknowledges that she is “opted out” (excluded) from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. The physician acknowledges that this contract shall not be entered into with the beneficiary, or the beneficiary's legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.
The physician acknowledges that she must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request.
The physician shall provide a copy of this contract to the beneficiary, or to his or her legal representative before items or services have been furnished to the beneficiary under the terms of this contract.
The physician acknowledges that she must enter into a contract for each opt-out period.
Beneficiary Obligations The beneficiary, or his or her legal representative, accepts full responsibility for payment of the physician's charge for all services furnished by the physician.
The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.
The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.
The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted- out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been 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 beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the physician during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.
The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative before items or services have been furnished to the beneficiary under the terms of this contract.
I understand that during the opt-out period, a Medicare Advantage plan may not by law make any payments to the physician for any Medicare items and services furnished to the beneficiary under this contract.