Vermont Code § 33 V.S.A. § 6504

Medicare beneficiary to sign statement
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§ 6504. Medicare beneficiary to sign statement
Annually and prior to treatment, a physician may request that a Medicare beneficiary
sign a statement prepared in accordance with this section to determine whether or
not the beneficiary may be balance billed. The exceptions contained in subdivision 6503(1) of this title shall not apply if the physician does not request that the beneficiary sign the statement.
The statement shall be prepared by the Department of Disabilities, Aging, and Independent
Living, and shall incorporate the exceptions contained in subdivision 6503(1) of this title.

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