Medicare Participation Agreement (CMS-460)

Practice Manager **Medicare Participating Physician or Supplier Agreement** **1. Provider Information:** * **Provider Name:** "Dr. Eleanor Vance, GP" * **Provider NPI:** 1234567890 * **Provider Specialty:** General Practice * **Clinic/Practice Name:** "Vance Medical Centre" * **Clinic/Practice Address:** 123 High Street, Anytown, AB1 2CD * **Contact Person:** Sarah Jenkins, Practice Manager * **Contact Phone Number:** 01234 567890 * **Contact Email:** sarah.jenkins@vancemedical.co.uk **2. Agreement Details:** * **Effective Date of Agreement:** 1 November 2024 * **Billing Number(s) Covered by Agreement:** 9876543210 (Main clinic billing number) * **Type of Participation:** Participating (Accepts Medicare Assignment) * **Explanation of Participating Status:** The Vance Medical Centre agrees to accept Medicare-approved amounts as payment in full for all Medicare-covered services rendered to Medicare beneficiaries. This means patients are only responsible for deductibles and co-insurance, and the clinic will not bill patients for the difference between its charges and the Medicare-approved amount. **3. Attestation:** * **Attesting Individual Name:** Sarah Jenkins * **Attesting Individual Title:** Practice Manager * **Date of Attestation:** 1 November 2024 **4. Confirmation of Understanding:** * **Has the provider reviewed the Medicare Participation Agreement terms and conditions?** Yes * **Does the provider understand their obligations under this agreement?** Yes * **Any specific questions or concerns noted by the provider or practice manager?** No **5. Actions Taken/Next Steps:** * **Agreement Submitted to CMS/Medicare Contractor:** Yes, submitted electronically via the PECOS system. * **Date of Submission:** 1 November 2024 * **Confirmation Number (if applicable):** CMS-123456789 * **Internal Record Keeping Updated:** Yes, updated practice management software with participating status. * **Staff Notified of Participating Status:** Yes, all administrative and billing staff informed of the change.