Private Contract Example - Provider Opt-Out of Medicare

If you have opted out of Medicare you are required to have a private contract with the beneficiary, in addition to filing for an affidavit with all Medicare contractors. The affidavit must be filed within 10 days of entering into the first private contract with a Medicare beneficiary. An example contract is now available to ensure you are meeting the requirements as an Opt-Out Provider. Select the file below to view.

Please also refer to the article "Providers Opting-Out of Medicare: Private Contracting" for additional requirements.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

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Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC


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RRB Specialty MAC Beneficiaries



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