Medicare Opt-Out Private Contract
allows Dr. Bradley VanHoose and/or Dr. Douglas Orzel to provide treatment to the above patient without being subject to Medicare limits. To do so, the law requires Dr. Bradley VanHoose and/or Dr. Douglas Orzel to “opt-out” of Medicare and that no Medicare claim be filed for the treatment of the above patient by Dr. Bradley VanHoose and/or Dr. Douglas Orzel.
Dr. Bradley VanHoose and/or Dr. Douglas Orzel represents that Dr. VanHoose and/or Dr. Douglas Orzel ‘s excluded from participation under the Medicare program under 1128, 1156 or 1892 of the Social Security Act; in addition, the above patient and Dr. VanHoose and/or Dr. Douglas Orzel agree that the above patient is not now facing an emergency or urgent health care situation.
By signing this contract, Patient does the following:
This contract shall remain in force and effect from the date it is signed by the above patient until the end of the term of Dr. Bradley VanHoose’s and/or Dr. Douglas Orzel’s current opt-out period. The expiration date of Dr. Bradley VanHoose’s opt-out period is January 10, 2024.
Original contract to be retained by dentist, a copy will be provided to the patient upon request.
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