Appointment Forms

Dr. Tansey and Dr. Cartaya have opt-out status with Medicare. In addition to the registration and agreement forms above, federal law requires their Medicare-enrolled patients to complete and sign a private contract before any health care is initiated, and to update every 2 years for ongoing care from our medical providers.

Medicare Agreement Form for Opted-Out Providers

Tips on Understanding Medicare

Can you file a claim with Medicare to help with reimbursement for our opted-out health care providers?

Yes, if Medicare is your primary insurance and your secondary insurance covers out-of-network providers’ services. You may submit your claim to Medicare to receive a document confirming that Medicare is not paying the claim (because our providers have opted-out), and then submit this denial of claim that you receive from Medicare along with a claims form and payment receipt to your secondary insurer to request reimbursement from them.

No, if your only health care insurance is Medicare or Original Medicare, as our providers have opted-out and Medicare provides no coverage or reimbursement to you or to us.

No, if you have a Medigap policy in addition to Medicare (or Original Medicare), as Medigap only ‘fills the gap’ in benefits for Medicare-covered services.

No, if you have a Medicare Advantage Plan, even if your plan offers expanded benefits. Your insurance company contracts with Medicare to provide Medicare Part A and Part B benefits and therefore cannot pay for services obtained from providers with opt-out status.

No, if Medicare is your secondary insurance. However, if your primary insurance (e.g., insurance through your employer) covers out-of-network providers’ services, you may submit your claim to your primary insurer.

If you are requesting other care providers send information for our doctors to review prior to your appointment or during your care, our consent form may be completed and sent to the provider to facilitate record requests. As many of our clients are working with providers at the University of Iowa Hospitals and Clinics, we have provided their specific directions for your convenience.

Consent to Obtain Information

Obtain University of Iowa Hospitals and Clinics Medical Records

If you are requesting that the Virtue Medicine providers provide your confidential records or information from our office, please click on the link below and complete the form for every person/office whom you would like to receive your information. Bring the signed forms to your next appointment, or mail them to our office, specifying all details that will help us accurately fulfill your request.

Consent to Release Information