WESTERN MASSACHUSETTS PODIATRY ASSOCIATES, P



WESTERN MASSACHUSETTS PODIATRY ASSOCIATES, P.C.

PODIATRIC MEDICINE AND SURGERY

evan p. CWASS, D.P.M., F.A.C.F.A.S. TELEPHONE: (413) 525-4373

Anthony L. Sarage, D.P.M. , f.A.C.F.A.S. FAX: (413) 525-9098

TO OUR MEDICARE COVERED PATIENTS

AS OF APRIL 1, 1988

PLEASE BE ADVISED THAT UNDER SECTION 1862 (A) (1) OF THE MEDICARE GUIDELINES, NOT ALL SERVICES PREVIOUSLY COVERED BY MEDICARE WILL BE CONSIDERED “COVERED SERVICES”. MEDICARE WILL STATE THESE SERVICES ARE MEDICALLY UNNECESSARY. THIS IS TO INFORM YOU THAT EVEN AFTER A REVIEW BY MEDICARE OF ANY PARTICULAR MEDICAL CIRCUMSTANCE, MEDICARE MAY STILL DISALLOW COVERAGE OF SOME TREATMENTS EVEN THOUGH OTHER TIMES THE SAME TREATMENTS ARE ACCEPTED AS COVERED SERVICES.

THERE ARE ALSO LIMITATIONS ON COVERAGE BASED ON THE FREQUENCY OF VISITS. PODIATRIC SERVICES SUBJECT TO LIMITATIONS INCLUDE:

1. DIABETIC FOOT CARE WITH CIRCULATORY DISORDER

2. MYCOTIC NAIL CARE

3. FOOT CARE FOR PATIENTS UNDER A PHYSICIAN’S CARE FOR CIRCULATORY DISORDERS

DIABETES AND CIRCULATORY DISORDERS MUST BE CONFIRMED BY YOUR PHYSICIAN, AND YOU MUST SEE THAT PHYSICIAN EVERY 6 MONTHS FOR TREATMENT OF THE LISTED CONDITION.

THERE ARE CERTAIN PODIATRIC SERVICES THAT ARE NOT COVERED. THESE SERVICES INCLUDE:

1. CUSTOM MOLDED SHOES (UNLESS THE PATIENT IS A DIABETIC)

2. SURGICAL SHOES

3. IN SHOE ORTHOTICS

4. FOOT CARE WITHOUT HAVING A CIRCULATORY DISORDER, OR MYCOTIC NAILS

NOTE: FOR THOSE MEDICARE PATIENTS WHO ELECT TO VISIT THIS OFFICE ON A MORE FREQUENT BASIS THAN IS ALLOWED BY MEDICARE, OR THOSE WHO ARE NOT COVERED FOR MEDICARE SERVICES “PAYMENT WILL BE REQUESTED AT THE TIME OF VISIT”.

IF YOU HAVE ANY QUESTIONS REGARDING THIS INFORMATION PLEASE INQUIRE.

THANK YOU,

EVAN P. CWASS, D.P.M.

ANTHONY L. SARAGE, D.P.M.

EVAN P. CWASS, D.P.M./ ANTHONY L. SARAGE, D.P.M. HAVE ADVISED ME THAT SPECIFIC SERVICES TO BE FURNISHED TO ME ON ANY OF MY VISITS MAY NOT BE REIMBURSED BY MEDICARE, AS IT MAY NOT BE CONSIDERED MEDICALLY REASONABLE OR NECESSARY BY THE MEDICARE CARRIER. EVEN SO, I HAVE ADVISED DR. CWASS/ DR. SARAGE TO PROCEED, AND I ASSUME RESPONSIBILITY FOR PAYMENT TO THIS OFFICE.

Have you had the Influenza Vaccine? Yes NO Have you had the Pneumoccal Vaccine? Yes NO

What was the last date you were seen by your Primary Care Doctor?

SIGNATURE OF PATIENT DATE

SIGNATURE OF PATIENT REPRESENTATIVE RELATION TO PATIENT

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85 SOUTH STREET

WARE, MA 01082

325B KING STREET

NORTHAMPTON, MA 01060

264 NORTH MAIN STREET

EAST LONGMEADOW, MA 01028

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