Medicare Private-Pay/Opt-Out Contract

Jessica Farber, Psy.D.
CA Licensed Psychologist, PSY 22360
3880 S. Bascom Ave., Suite 202, San Jose, CA 95124
Phone: (408) 981-8676, Fax: (408) 371-9193
www.DrJessicaFarber.com

This form is meant to inform you that I, Jessica Farber, Psy.D., have decided to opt-out from accepting Medicare Payments, starting on January 1, 2026. Because I have opted-out, Medicare requires that I have you sign a private-pay medical services contract before I treat you. (The form on this website is for your information only, and reading it does not constitute a professional relationship with me.)

Please be aware of the following information:

WHO PAYS FOR SERVICES?

You pay the bill. You will have to use your own money to pay the ENTIRE cost of my services.

ARE THERE CHARGE LIMITS?

No, Medicare charge limits DO NOT apply to treatment you receive from me through this private-pay medical services contract. I am able to charge you whatever amount you and I agree to.

WILL MEDICARE HELP PAY?

No, Medicare will NOT help pay your bill. Because I separated from Medicare, it is against the rules for you to send a bill to Medicare for my services or ask me to send the bill to Medicare for you.

BUT ISN’T THIS A MEDICARE-COVERED SERVICE?

Yes and no. Yes, Medicare would pay for the same treatment from a provider who is connected to Medicare. No, Medicare won’t pay because I have separated myself from Medicare.

WHAT OPTIONS DO I HAVE?

You have the right to get your treatment from a provider connected to Medicare or from me, a provider separated from Medicare. Even if you get your treatment from me, you can still get other products and services from providers connected to Medicare. These providers are not required to have you sign private-pay medical services contracts.

WILL MY MEDIGAP OR OTHER SUPPLEMENTAL PLAN HELP PAY?

No, Medigap plans WILL NOT help pay for products or services you get from me. If you have some other medical insurance plan, it MIGHT or MIGHT NOT help pay your bill.