Nurse Practitioner Opt Out

Important!

Please go to signature.imageonline.co. Using a computer (we don't recommend using a smartphone) you can draw your signature in the box and click the "download signature" button.

Please draw as "clean" and legible signature as possible.

After you have done this, complete the form below and upload your digital signature image by clicking the "Upload Digital Signature Image" button below.

"*" indicates required fields

Your Name*

First Last

Your Phone Number*

Your Email Address*

Clinic Name*

Social Security Number*

Enter numbers only.

Date of Birth*

Your Individual NPI*

Medicare PTAN

If you had one assigned already. If not, leave blank.

State License Number*

State Where License Issued*

License Effective Date*

I understand that by signing this form, I am agreeing to have The Wellness Way opt me out of Medicare.*

Yes

I understand that by signing this form, I will still be able to write prescriptions, as I am choosing to still order/refer in regards to Medicare.*

Yes

I understand that by signing this form, I will not be able to rejoin Medicare for at least 2 years from when I am opted out.*

Yes

I give Advocate Insurance Billing permission to use my digital signature for purposes of this opt out and signing any paperwork necessary.*

Yes

Upload Digital Signature Image*

Max. file size: 256 MB.