35 Collier Road, NW
Atlanta, GA 30309
I, Dr. Jphn Tumeh, have not been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act (NPI 1053540088).
I (the Medicare beneficiary) or my legal representative understand the Medicare limits do not apply to what Dr. John Tumeh may charge for items or services furnished.
I (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Dr. John Tumeh to submit a claim to Medicare.
I (the Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any items or services furnished by Dr. John Tumeh that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
I (the Medicare beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted out of Medicare and I am not 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 effective date of the opt-out affidavit is January 19, 2018.
I (the Medicare beneficiary) or my legal representative understands that Medigap plans do not and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
This contract cannot be entered into by me, (Medicare beneficiary), or by my legal representative during a time when I, (the Medicare beneficiary), require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.38 of the Medicare Carriers Manual.)
I (the Medicare beneficiary) or my legal representative will receive or have received a copy of this contract before items or services are furnished to me under the terms of this contract.
I, Dr. John Tumeh, will retain the original contract for the duration of the opt-out period.
I, Dr. John Tumeh, will supply CMS with a copy of this contract upon request.
Provider's NPI: 1053540088