Patient Forms

Medicare Private Contract Form

Complete the form below before your visit. If you have questions, please call Fujioka Family Dentistry at 360-696-4439.

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Fujioka Family Dentistry
215 NW 78th St
Vancouver, WA 98665
360-696-4439

MEDICARE PRIVATE CONTRACT

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)

Patient Name:

FirstLast

Initials

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.

Initials

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 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.

Initials

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.

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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 the Patient until the end of the term of the Dentist's current opt-out period.

Agreement Accepted by:

Dentist: Aimee M. Fujioka, DMD

Patient Signature:

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