Fujioka Family Dentistry 215 NW 78th St Vancouver, WA 98665 360-696-4439
This contractual agreement is between Dr. Aimee M. Fujioka ("Dentist") whose principal place of business is at 215 NW 78th Street, Vancouver, WA 98665 and ("Patient"), a Medicare Part B beneficiary. As a Dentist that has opted out of the Medicare program on September 30, 2006 indefinitely, Dr. Aimee M. Fujioka 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. Aimee M. Fujioka 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 Dentist according to Dentist's fee schedule. Patient also agrees, understands, and expressly acknowledges the following: (Initial all)
This contractual agreement shall remain in force from the date it is signed by the Patient until the end of the term of the Dentist's current opt-out period.
Agreement Accepted by: