Medicare opt out letter: Fill out & sign online

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Click ‘Get Form’ to open the Medicare Opt-Out Affidavit in our editor.
Begin by filling in your name as the Therapist at the top of the form. This personalizes the affidavit and identifies you as the provider.
In Section 1, confirm your commitment to provide services only through private contracts during the opt-out period, ensuring compliance with Medicare regulations.
Complete Section 2 by acknowledging that you will not submit any claims to Medicare for services provided during the specified two-year period.
Fill out your Principal Office Address, City, State, Zip, Telephone Number, National Provider Identifier (NPI), and License Number(s) in the designated fields.
Sign and print your name at the bottom of the form. Ensure all information is accurate before proceeding.
Finally, follow instructions for notarization and ensure two copies are made—one for your records and one to send to CIGNA Government Services.

Start using our platform today to easily complete your Medicare Opt-Out Affidavit for free!

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medicare opt out letter example

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medicare opt out letter template

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