|
Medicare By signing this contract I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon submit) a claim to Medicare or its agents for services provided by Drs. Scully, Matheson, Fonseca, & Parworth, even if such services would otherwise be covered. I agree to be fully responsible, through insurance or otherwise, for payment of services rendered by Drs. Scully, Matheson, Fonseca, & Parworth, and I understand that no claims will be submitted to Medicare and no Medicare reimbursement will be provided for these services. I understand that there are no limits specified by Medicare as to the amounts that may be charged by the oral and maxillofacial surgeon for services provided. I understand that Medigap plans do not, and other health and medical care insurance plans may elect not to, make payments for such services. I understand that I have the right to have services provided by other oral and maxillofacial surgeons or other practitioners for whom Medicare payment would be made, and that I am not compelled to enter into private contracts that apply to covered care furnished by other health care professionals who have not opted-out. I understand that Drs. Scully, Matheson, Fonseca, & Parworth, is not excluded from participation in the Medicare program under Section 1128 of the Social Security Act or pursuant to any other legal authority. This contract is effective on 10-01-2008, and it will expire on 09-30-2010.
Patient’s Name: _____________________________________Date: _______________ Patient’s Signature: ______________________________________________________
Oral and Maxillofacial Surgeon’s Signature: __________________________________
|