HomeMy WebLinkAboutResolutions 84-241 N.C.S. 10/01/19841 .. __.. r . T, f ._.:.......
T
~,`
• Resolution No. s ~ -? 41 N. C. S.
f
of the City of Petaluma, California
AUTHORIZING AN ,AGREEMENT
WITH MEDICA'RE'
BE IT RESOLVED THAT the Mayor: o;r. C'ty Manager is hereby
authorized to enter unto and sign an agreement with Medicare
as a, Participating Supplier.
Under the power-^and; authority ,conferred upon .this Council `by the Charter of said .City.
Thereby cetify the foregoing Reso_ lution was intoduced and adopted'. by the Approved ;as to
Council of the Cit of Petaluma at a Re
Y ~ mar) /t~~~~~~~~ meeting form
on the; ... .1st------•--. day of ... October ......::: ...:...::.. is ~:~_., by the.
following, voted __'
•- --...... y..: -..
City Attorne
.AYES= Battagla%Ten'cer/Cavariagli/Bal-snaw./V.~'~.. Bond/`~ayor ~Zattei
NOES: None .
ABSENT: er. -y ~'~
ATTEST,:: :....... .. ...: ....:.. .....:.............:•--.............,:..
City Cle`;k. Mayon
• Council Fila ,: -.
Foam CA:2;7781. Rte. No:..._..~.4..... ~.~~. ~ • C • S . '
From:
To: Medicare
Participating Physician/Supplier Department
P.O.'.Box 7168
San Francisco, CA 94120
medicare
Participating Physician/Supplies Department
P.O. Boz?168, San' Frrahcisco, CA 94120
049 00 ~ C1 ZZZ31259C 59
GI~IY OF P~TALUMA AiNB SVG
POB[IX61
PETALUMA, GA 94452
MB 58.5OM 9/84..
PLACE
STAMP
_ HERE `~
~~
~,
~~~
:~,
.~_ ~_
(:-
'..Presort ~
FIRST GLASS
U.S POSTAGE
PAID
PERMIT NO. 10033 i
SAN FR9N01SC0. O'A
~~~~~n~r~~3
.S~p 1 X984
Alts ~ ANCE 07V SIpN ...
,,
SEPTEMBER 194
Medicare
Physician and Supplier
Participating Agreement
.(Second Notice)
r
MEDICARE
PARTICIPATING PHYSICIAN
AND SUPPLIER PROGRAM
The Medicare. Participating Physician and Supplier Program was created by the Deficit Reduction Act of 1984, which
became law on July 18, 1984.
A special August 1984 Medicare notice announced the details of the Medicare participation program and also
provided a Medicare Participating Physician or Supplier Agreement to be completed by those physicians and
suppliers wishing to become a Medicare participating physician or supplier for the year beginhing October 1,1984.
The purpose of this notice is to remind physicians and suppliers of the October 1,1984 deadline for enrolling in the
Medicare participation program for the year October 1, -1984 -September 30;1985.
After October 1, 1984, only those physicians and suppliers who are new or change practice locations from one
prevailing charge locality to another will 6e allowed to join the Medicare participation program for this year.
Fo.r your convenience,, we have included another agreement form with this notice. If you decide to participate, the
Medicare Participating Physician or SupplierAgreement must be returned to the:address below by October 1,1984. If ~
you did not receive the August notice announcingrthe details of the program or if you need more information, please ~,
call us at (415) 445-5042. _
~o
v
F-
,,:. y. Kathleen Scott
Medicare Participating Physician/Supplier Department
P.O. Box 7168
San Francisco, CA 94120
Please return the original, completed agreement with this notice io: Medicare Participating Physician/-
SupplerDepartment, P.b,Box 7168, San Francisco, CA 94120. If you wish to return the agreement without
theenvelope,,you may told the agreement so thatthe Medicare Participating Physician/Supplier Depart-
ment address is displayed on top and affix postage.
Please return this original form to Medicare Participating Physician/Supplier Department, P.O. Box 7168,
San Francisco, CA 94120. Medicare will return a copy to you for your records.
Form Approved
OMB No. 0938-0373
MEDICARE
PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
Physician or Supplier
Name(s) and Address of Participant* Identification Code(s)*
The above named person or organization, called "the participant," hereby enters into an agreement with the Medicare
program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to
accept assignment under the Medicare law and regulations, and which are furnished while this agreement is in effect.
1. Meaning of Assignment -for purposes of this agreement, the participant accepts assignment of the Medicare Part
B payment when the participant requests direct Part B payment from the Medicare program. Under an assignment,
the approved charge, determined by the Medicare carrier, shall be the full charge for the service covered under Part B.
The participant shall not collect from the beneficiary or other person or organization for covered services more than
the applicable deductible and coinsurance.
2. Effective Date - If the participant files the agreement with any'Medicare carrier during the 3-month period July
through September of any calendar year; the agreement becomes effective oh October 1 of that year.
3. Term and Termination ofAgreement -Thisagreement shall continue i n effectthrough Setember 30 fol lowing the
date the agreement becomes effective and shall be renewed automatically for each 12-month period October 1
through September 30 thereafter unless one of thefollowing occurs:
a. Before October 1 of any year the participant notifies in writing every Medicare carrier with whom the participant
has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the erid of
the current term. In the event such notification is mailed or delivered on or before September 30 of any year, the
agreement shall end on September 30~of that year.
b, The Health Care Financing Administration may find, after notice to and opportunity for a hearing for the
participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is
made, the Health Care Financing Administration will notify the participant in writing that the agreement will be
terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the
agreement.
'Listall names and identification codes under which the participant files claims with the carrier with whom this agreement is being filed.
Signature of participant
(or authorized representative
of participating organization)
Title
(If signer is authorized
representative of organiz-afi'orr)'
Date
Office phone number Medical specialty
(including area code)
NOTE: Thetelephone numberand medical specialty indicated above may be published in the Medicare Participating
Physician/Supplier Directory.
Received by
For Carrier Use Onl
(name of caiiiei)
Effective date
Initials of carrier official