Medicare Private Contact
THIS CONTRACTUAL AGREEMENT IS BETWEEN DR. SHARAD PANDHI, D.D.S. (“DENTIST”) WHOSE PRINCIPAL PLACE OF BUSINESS IS AT 5828 N ORACLE RD SUITE #100, TUCSON, AZ 85704 AND
(“PATIENT”). A MEDICARE PART B BENEFICIARY. AS A DENTIST THAT HAS OPTED OUT OF THE MEDICARE PROGRAM ON 07/01/2004 FOR A PERIOD OF AT LEAST 2 YEARS, DR. SHARAD PANDHI HAS INFORMED PATIENT THAT HE/SHE PROIDES TO ANY MEDICARE BENEFIIARY IS NOT SUBJECT TO MEDICARE LIMITS PERSUANT TO DENTIST “OPT OUT”AGREEMENT WITH MEDIACRE 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. SHARAD PANDHI 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 LEGAL REPRESENTATIVE, AGREES TO PAY DENTIST ACCORDING TO DENTIST’S FEE SCHEDULE. PATIENT ALSO AGREES, UNDERSTANDS, AND EXPRESSLY ACKNOWLEDGES THE FOLLOWING: (PLEASE INITIAL)
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PATIENT IS NOT CURRENTLY IN AN EMERGENCY HEALTH CARE SITUATION
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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.
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PATIENT ACKNOWLEDGES THAT NEITHER MEDICARE’S FEE LIMITATIONS NOR ANY OTHER MEDICARE REIMBURSEMENT REGULATIONS APPLY TO SERVICES PROVIDED BY DENTIST.
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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.
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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.
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PATIENT ACKNOWLEDGES THAT HE/SHE HAS A RIGHT, AS A MEDICARE BENEFICIARY; TO OBTAIN MEDICARE COVERED ITEMS AND SERVICES FROM DENTIST WHO HAVE NOT OPTED OUT OF MEDICAREAND THAT PATIENT IS NOT COMPELLED TO ENTER INTO PRIVATE CONTRACTS THAT APPLY TO OTHER MEDICARE COVERED SERVICES FURNISHED BY OTHER DENTIST WHO HAVE NOT OPTED OUT.
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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.
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PATIENT ACKNOWLEDGES THAT A COPY OF THIS AGREEMENT HAS BEEN MADE AVAILABLE TO HIM/HER. THIS CONTRACTUAL AGREEMENT SHALL REMAIN FORCE FROM THE DATE IT IS SIGNED BY PATIENT UNTIL THE END OF THE TERM OF THE DENTIST’S CURRENT OPT OUT PERIOD.
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AGREEMENT ACCEPTED BY:
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DENTIST SIGNATURE
PATIENT SIGNATURE
Date
THE MEDICARE PROGRAM DOES NOT COVER ROUTINE DENTAL SERVICES. THE MEDICARE LAW CLEARLY EXCLUDES COVERAGE “FOR SERVICES IN CONNECTION WITH THE CARE, TREATMENT, FILLING, REMOVAL OR REPLACEMENT OF TEETHOR STRUCTURES DIRECTLY SUPPORTING TEETH” AND DENTISTS MAY NOT BE REQUIRED TO SUBMIT MEDICARE CLAIMS FOR SUCH SERVICES.
FOR PEOPLE WITH MEDICARE, THIS MEANS THAT MEDICARE WILL NOT PAY FOR MOST ROUTINE DENTAL CARE, SUCH AS FILLINGS, CLEANINGS, X-RAYS, AND DENTURES, EVEN IF THOSE SERVICES ARE PERFORMED IN A HOSPITAL. PAYMENT IS YOUR RESPONSIBILITY.
A NARROW EXCEPTION PERMITS COVERAGE OF CERTAIN DENTAL SERVICES THAT ARE NECESSARY TO THE PROVISIONOF CERTAIN MEDICARE COVERED MEDICAL SERVICES. FOR EXAMPLE, MEDICARE MAY COVER THE FOLLOWING SERVICES:
*EXTRACTION OF TOOTH AS PART OF A REPAIR OF A FRACTURED JAW.
*MAXILLOFACIAL SURGERY FOR PATHOLOGICAL OR TRAUMATIC MEDICAL CONDITIONS (FOR EXAMPLE, IN CASE OF SERIOUS INJURY).
*PROSTHETIC REHABILITAIONTO REPLACE OR TREAT CERTAIN ORAL AND/OR FACIAL STRUCTURES RELATED TO COVERED MEDICAL AND SURGICAL INTERVENTIONS (FOR EXAMPLE, CANCER SURGERY).
*EXTRACTION OF TEETH PRIOR TO RADIATION TREATMENT OF JAW. *ORAL EVALUATION PRIOR TO KIDNEY TRANSPLANTATION. MEDICARE MAY ALSO COVER CERTAIN MEDICAL PROCEDURES THAT DENTISTS ARE LICENSED TO PERFORM (FOR EXAMPLE, A BIOPSY FOR ORAL CANCER).
THESE ARE NOT ALL INCLUSIVE LISTS. THESE EXAMPLES ARE FOR ILLUSTRATIVE PURPOSES.
PATIENT SIGNATURE