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PARTICIPATING AGREEMENT
The Medicare Participating Physician or Supplier Agreement is a voluntary agreement. You need not be participating to be enrolled in the Medicare Part B Program. If you do agree to become participating, the enclosed Medicare Participating Physician or Supplier Agreement must be signed, dated and returned to our office within 90 days. Please read all information enclosed carefully before signing this document as you will be bound to this agreement until the next enrollment period.
If you are joining an established group, you will assume the group’s participation status.
If you are forming a new group or starting a new practice, the effective date of your participation status will be the date of the postmark from the United States Postal Service.
Note: A participation agreement applies to all services in all localities and under all names and identification numbers under which you do business. However, if you are a member of a group and have an individual practice outside the scope of the group practice, using different tax identification numbers and or social security numbers, you may choose whether or not to participate in that practice regardless of the group’s participation status. A separate participation agreement must be on file for each entity (different tax ID’s).
You will receive an initialed copy of this agreement confirming receipt by the carrier. If you do not receive a copy within 60 days, please contact our office at 607-766-6000, and ask for the Provider Enrollment Unit.
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