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 rendered 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.
