TAX EQUITY AND FISCAL RESPONSIBILITY ACT(TEFRA)
PUBLIC LAW 97-248

SECTION III: THE MEDICARE PROGRAM MAY NO LONGER REIMBURSE FOR THE EXTRA COST OF PRIVATE ACCOMMODATIONS UNLESS THE PRIVATE ROOM ACCOMMODATIONS USED BY A BENEFICIARY ARE MEDICALLY NECESSARY. THE REGULATIONS FOR THIS PROVISION BEGAN ON OR AFTER OCTOBER 1, 1982.

I HAVE REQUESTED THE USE OF A NON-MEDICALLY NECESSARY PRIVATE ROOM AND HAVE BEEN INFORMED OF THE CHARGES THAT WILL BE MY RESPONSIBILITY.

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 Patient or Guarantor Signature                                                                                Date