To My Medicare Eligible Patients

To My Medicare Eligible Patients:

This is to let you know that under a law passed by Congress in 2003, I have decided not to participate in the Medicare system. I believe this decision will allow me to provide the best possible care to you, at fees we agree upon. This also permits us to proceed with your treatment without worrying about Medicare limitations or red tape. Very little dental care is covered by Medicare, and it’s unfortunately very difficult for my office to handle all of the paperwork and red tape of this complex governmental structure. My non-participation in Medicare means that you will pay me directly. For this to happen, the law requires us to enter into a contract containing very specific terms.

If you agree that this approach will work for your needs as well, please sign and date the attached contract. Please simply note that this would mean I regrettably would be unable to perform any Medicare-covered procedures for you.

Thank you for your understanding. I value you as a patient and value our professional relationship and hope this letter helps you understand the situation.

Respectfully,

Dr. Cascino, DDS

Dr. Pizzurro, DDS

Medicare Opt Out Private Contract

This contract is between Susan A. Cascino, DDS and ______

(Medicare beneficiary, referred to in this contract as “Patient”).

Dr. Cascino has elected to opt out of Medicare. A dentist who opts out is not required to submit claims on behalf of beneficiaries and is not subject to Medicare limits on charges for covered services.

Dentist represents that Dentist is excluded from participation under the Medicare program under 1128,1156 or 1892 of the Social Security Act.

Patient (or Patient’s legal representative) and Dentist agree that patient is not now facing an emergency or urgent health care situation.

By signing this contract, Patient (or Patient’s legal representative) does the following:

Accepts full responsibility for payment of Dentist’s charge for all services furnished by Dentist;

Understands that Medicare limits do not apply to what the Dentist may charge for items or services furnished by the Dentist;

Agrees not to submit a claim to Medicare or to ask Dentist to submit a claim to Medicare;

Understands that Medicare payment will not be made for any items or services furnished by Dentist that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;

Enters into this contract with the knowledge that Patient has the right to obtain Medicare covered items and services from dentist, physicians, and practitioners 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 dentist, physicians, or practitioners who have not opted out;

Understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;

The known effective date of the opt-out period is: April 22, 2015

The known expiration date of the opt-out period; April 22, 2017

This contract shall remain in force and effect from the date it is signed by Patient until the end of the term of the Dentist’s opt-out period which will continue to be extended every 2 years unless otherwise notified.

Accepted and Agreed: ______

Patient or Patient’s Legal Representative

Date: ______

PERIODONTAL THERAPY IMPLANTOLOGY

Susan A. Cascino, DDS Robert E. Pizzurro, DDS

Practice Limited to Periodontics Diplomate, American Board of Periodontology

10 West Martin Avenue Suite 211

Naperville, Illinois 60540

630-355-5010/Fax: 630-355-4317