Get the free Opt-Out Affidavit - Noridian - HMSA Dental

Opt-out Affidavit Provider Name (First) (Middle) (Last) (Cred) Provider Address (Street) (City) (ST) (Zip) Social Security Number: Date of Birth: Specialty Medicare PLAN(s) NPI Number Telephone ()

How to fill out opt-out affidavit - noridian

How to fill out opt-out affidavit - Noridian?

1. Obtain the opt-out affidavit form from Noridian's official website or contact their customer service for assistance.
2. Fill out your personal information accurately, including your name, address, phone number, and National Provider Identifier (NPI) number.
3. Provide the effective date of your opt-out status, which is the date you will no longer be participating in Medicare.
4. Indicate the reason for opting out, such as retirement, practicing in a non-Medicare capacity, or joining a concierge practice.
5. Include your signature and date at the bottom of the affidavit to verify the accuracy of the information provided.
6. Send the completed form to Noridian according to their specific instructions, such as via mail, fax, or electronic submission.

Who needs opt-out affidavit - Noridian?

1. Healthcare providers or practitioners who wish to opt-out of Medicare and no longer participate in the program.
2. Individuals who have transitioned into a non-Medicare practice model or are retiring from Medicare-based services.
3. Providers who are joining a concierge practice or implementing a direct pay model that does not involve Medicare.

It's important to note that the opt-out affidavit is specific to Noridian, a Medicare Administrative Contractor (MAC) that operates in certain states. If you are unsure whether Noridian is your MAC or have any specific questions regarding the opt-out process, it's recommended to reach out to Noridian directly for assistance.

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