OnCallMD, LLC Medicare Private Contract

Effective Date: 9/1/2025
Practice: OnCallMD, LLC
Address: 1831 W Evans Street, Suite 210, Florence, SC 29501
Email: contactus@theoncallmd.com

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1. Purpose of This Contract

This Private Contract is between OnCallMD, LLC (the “Practice”) and the undersigned patient (“Patient”), who is eligible for Medicare benefits. The purpose of this contract is to comply with Section 1802(b) of the Social Security Act and related regulations, which require a private agreement when a Medicare beneficiary chooses to receive medical services from a physician or practitioner who has opted out of Medicare.

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2. Acknowledgments by Patient

By signing below, Patient understands and agrees to the following:

1. Physician Opt-Out Status
    

   • The physicians of OnCallMD, LLC have elected to opt out of Medicare for purposes of these concierge and telehealth services.
      

2. No Medicare Reimbursement
    

   • Neither OnCallMD, LLC nor its physicians will submit a bill or claim to Medicare for the services provided under this agreement.
      

   • Patient agrees not to submit any claim to Medicare or to ask the Practice to submit one.
      

3. Out-of-Pocket Responsibility
    

   • Patient accepts full financial responsibility for all services provided by OnCallMD, LLC.
      

   • Patient understands that Medicare limits, coinsurance, and deductibles do not apply to these services.
      

   • Patient agrees to pay according to the Practice’s current Fee Schedule (attached as Exhibit A), which may be updated periodically with notice.
      

4. Right to Medicare-Covered Services Elsewhere
    

   • Patient understands they have the right to seek services from physicians or practitioners who are enrolled in Medicare and that those services may be covered and reimbursed by Medicare.
      

   • Patient is not required to receive services from OnCallMD, LLC.
      

5. Emergency/Urgent Care Exception
    

   • This contract does not apply to emergency or urgent care services. If Patient requires emergency care, OnCallMD physicians will follow applicable Medicare billing rules.
      

6. Duration of Contract
    

   • This contract will remain in effect for two (2) years from the date of signature unless terminated earlier by law or mutual agreement.
      

   • Patient may enter into a new contract if they wish to continue receiving services after this period.