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Notice to Patients About the Use of Medicare Information

We are authorized by the Center for Medicare/Medicaid Services to ask you for information needed by the administration of the Medicare program. Authority to collect information is in section 205(a), 1872 and 1875 of the Social Security Act as amended.

The information we obtain to complete a Medicare claim is used to identify you and determine your eligibility. It is also used to decide if the services and supplies you receive are covered by Medicare and to insure that proper payment is made.

The information may also be given to other providers of services, carriers, intermediaries, medical review boards, and other organizations or federal agencies as necessary to administer the Medicare program.

With the one exception discussed below, there are no penalties under Social Security law for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of Medicare claims. Failure to furnish any other information, such as name or claim number, would delay payment of the claim.

It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether workman’s compensation will pay for treatment. Section 1877(a)(3) of the Social Security Act provides criminal penalties for withholding this information.