Oral & Maxillofacial Surgery of Greater Grand Rapids, PLLC

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:

1. Agrees not to submit a Medicare claim (or to request that Dr. Bradley VanHoose and/or Dr. Douglas Orzel submit a claim) for services or items supplied by Dr. Bradley VanHoose and/or Dr. Douglas Orzel, even if they are otherwise covered under Medicare.
2. Agrees to be responsible, whether through insurance of otherwise, for payment of services or items supplied by Dr. Bradley VanHoose and/or Dr. Douglas Orzel, and understands that no reimbursement will be provided under Medicare for those services or items: in particular, the above patient will pay for such services at Dr. Bradley VanHoose’s and/or Dr. Douglas Orzel’s usual rate (or any other agreed upon rate), in accordance with Dr. Bradley VanHoose’s and/or Dr. Douglas Orzel’s payment policies.
3. Acknowledges that Medicare limits do not apply to amounts that Dr. Bradley VanHoose and/or Dr. Douglas Orzel may charge for such services or items.
4. Acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to, make payments for items and services covered by this contract, because payment is not made under Medicare, and
5. Acknowledges that the above patient has the right to have such services or items provided by other dentists or practitioners for whom payment would be made under Medicare. (Patient is not required to enter into private contracts that apply to other Medicare covered services furnished by other dentists who have opted out).

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.