2208 University Blvd Suite 102
Birmingham, AL 35233

Alabama Lifestyle Medicine - Dr. Noah Gudel, D.O.

Medicare Opt-Out Contract

Alabama Lifestyle Medicine

This agreement is between Noah E. Gudel, D.O., whose principal place of business is 2208 University Blvd, Birmingham AL 35233, and

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and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on 1 October, 2021, and continuing indefinitely. The physician is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.

Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:

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