Signature of Dentist: ________________________________________________________
Printed Name of Dentist: _____________________________________________________
Date: _____________________________________________________________________
MEDICARE PRIVATE CONTRACT
This contractual agreement is between
Dr. _______________________________________________
("Dentist")
whose principal place of business is at _________________________(Street.
City. Slate. Zip)
and _____________________________________________________("Patient"),
a Medicare Part B beneficiary.
As a Dentist that has opted out of the Medicare program
on (effective date) for a period of at least two years,
Dr. (Dr. name) has informed Patient
that treatment he/she provides to any Medicare beneficiary
is not subject to Medicare limits. Pursuant to Dentist's
"Opt Out" agreement with Medicare, Patient
has also been informed that Dentist is prohibited
from billing Medicare for services provided to Patient.
As required by law, this agreement clearly states
that Dr.(Dr. name) is a provider in good standing
with the Medicare program under Section 1128, 1156
or 1892 of the Social Security Act.
By signing this contract, the beneficiary or the
beneficiary's legal representative, agrees to pay
Dr. (name) said Dentist according to Dentist's fee
schedule. Patient also agrees, understands, and expressly
acknowledges the following: (Initial)
________ Patient is not currently in an emergency
health care situation.
________ Patient agrees not to submit a claim (or
to request Dentist to submit a claim) to the Medicare
program even if services may be covered by Medicare
Part B.
________ Patient acknowledges that neither Medicare's
fee limitations nor any other Medicare reimbursement
regulations apply to services provided by Dentist.
________ Patient understands that Medicare payment
will not be made for any items or services furnished
by the Dentist that would have otherwise been covered
by Medicare if there were no private contract and
a proper Medicare claim were submitted.
________ Patient acknowledges that Medigap plans will
not provide payment for services rendered because
payment will not be made under the Medicare program.
Other supplemental plans may also deny payment.
________ Patient acknowledges that he/she has a right,
as a Medicare beneficiary, to obtain Medicare covered
items and services from dentists who have not opted
out of Medicare and that Patient is not compelled
to enter into private contracts that apply to other
Medicare-covered services furnished by other dentists
who have not opted out.
________ Patient agrees to be responsible, whether
through insurance or otherwise, to make payment in
full for services provided by Dentist and acknowledges
that Dentist will not submit a claim for Medicare
reimbursement.
________ Patient acknowledges that a copy of this
agreement has been made available to him/her.
This contractual agreement shall remain in force from
the date it is signed by Patient until the end of
the term of the Dentist's current opt-out period.
The expected expiration date of the Dentist's opt-out
period is ________________ (put in opt out
date 2yrs from said date)
Agreement Accepted by: ___________________________________
(Dentist)
________________________________________________________
(Patient)
Date of Signatures: _______________________________________________________
You can obtain the address for each state by clicking
on the following link:
http://www.cms.hhs.gov/providers/enrollment/contacts/
