NEW Patient Forms Easy as 1, 2, 3
On your first visit to our office, we will have you sign the forms and allow you to ask us questions in person. The security and privacy of your data are our primary concerns, and we have taken every precaution to protect them. Click here to download it: You will need Adobe Acrobat Reader installed to view or print these forms.
Medical History, Financial Agreement, Insurance Form, Cancelation Policy
Medicare Opt-Out Private Contract 2024
- Please print and fill these out before your office visit.
- We ask you to please complete them ahead of time and return them via secure email or fax.
- Please call us with any questions at 503-385-8821.
- Wear a mask as they are required. We have them available for purchase if you forget yours.
Please allow approximately 60-90 minutes for your initial visit. If you have pain or an emergency, every attempt will be made to see you that day.
About Medicare Opt-Out Form:
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 the fees we agree upon. This lets us proceed with your treatment without worrying about Medicare limitations or red tape. Very little dental care is covered by Medicare Part B, 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 services covered by Medicare Part B. The law requires us to enter into a contract containing very specific terms for this to happen.
If you agree that this approach will also work for your needs, please sign and date the attached contract. I certainly will understand if you decide that you do not wish to sign the contract. Please note that this would mean I regrettably cannot perform any Medicare Part B-covered procedures for you.
I appreciate your understanding. I value you as a patient and value our professional relationship, and I hope this letter helps you understand the situation.