Ophthalmology and Optometry Coding Alert

Date:

This letter serves to document an agreement between me, John Doe, MD, and XYZ Skilled Nursing Facility. At your request, I may provide medically appropriate services to patients from your facility who are classified by the Medicare program as under skilled nursing facility care. Following evaluation and treatment, my office will send an invoice directly to your facility for reimbursement of the medical care services I have provided, at your request, to these patients. Payment will be expected regardless of your facility's reimbursement status with Medicare.

Payment should be mailed directly to the address below within 10 days following receipt of my invoice.

Provider tax ID number:

Please send payment to:
Billing Office Address
City, State, ZIP code

Signatures by both parties below acknowledge and consent to the above agreement.

Signature of Physician and Date _____________________ Signature of SNF and Date_____________________

*Editor's note: Consider having an attorney review any agreement or contract you plan to use before you obtain the signatures, to ensure the contract is in fact legal and binding.