Tree of Life Health Solutions
Private Billing and Payment Contract Regarding Medicare, Medicaid, Tricare/Military, and All Insurance Plans
Providers: David M. Rohrer, MD and Pauletta J. Hummel, FNP
and Kim J. Lyons, DC, ND

Definitions: Patient and Beneficiary are the same individual.  This is the individual receiving services by the providers.  
Representative: The individual responsible for health care decisions and financial responsibilities of the beneficiary/patient.  

Patient/Beneficiary: ___________________________________ Date: ___________________

*Our providers do NOT participate with ANY Medicare, Medicaid, Tricare/Military, or Other Insurance Plans, as they have chosen to opt out of these contracts.  The providers are excluded from Medicare under the Social Security Act 1156 as a personal choice in regards to all services provided at Tree of Life Health Solutions.
*The Beneficiary/Patient or his/her legal representative accepts full responsibility for payment of the providers' charges for all services furnished by them.  These payments are due at the time of services, no exceptions.  We accept cash, check, and credit as forms of payment.  A convenience fee will be applied to all credit card transactions.  This is not applied to debit or HSA debit cards.  We do NOT offer payment plans.
* The Beneficiary/Patient or his/her legal representative agrees not to submit a claim to Medicare/Medicaid/Tricare, nor ask the provider to submit a claim on his/her behalf.  Private insurance claims may be submitted by the beneficiary or beneficiary's representative independently.  To clarify, we do not submit claims for billing on behalf of patients. 
*The Beneficiary/Patient or the his/her legal representative understands that Medicare or Medicaid payment will not be made for any items or services furnished by the providers that would have otherwise been covered by Medicare, Medicaid, or Tricare.  There is no private contract with the providers with these government services, therefore claims will not be paid to beneficiaries.  This may apply to private insurance as well in regards to out-of-network providers.
*The Beneficiary/Patient or his/her legal representative is entering into this contract with the knowledge that the beneficiary has the right to obtain Medicare, Medicaid, Tricare/Military, and ALL Insurance Plans covered items and services furnished by other physicians or practitioners who have not opted out.  To clarify, the patient has the right to seek healthcare in by a provider that takes insurance.  
* The Beneficiary/Patient or his/her representative understands that Medigap plans do NOT, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare, Medicaid, Tricare/Military, and All Insurance Plans.  
* This contract is renewed at minimum every two years effective January 1st of each odd year.  

Beneficiary/Representative Printed Name: ______________________________________
Beneficiary/Representative Signature: __________________________________________
Provider Signatures (Automatic):
David M. Rohrer, MD
Pauletta J. Hummel, FNP
 Kim J. Lyons, DC, ND