Private Contract Agreement
This contract between Prosthodontics Intermedica (“Dentist”) and _______________________
(Insurance beneficiary, referred to in this contract as “Patient”) allows Dentist to provide
treatment to Patient without being subject to insurance limits.
By signing this contract, Patient does the following:
(i)
Agrees to be responsible, whether through insurance or otherwise, for payment
of services or items supplied by Dentist; in particular, Patient will pay for such
services at Dentist’s usual rate (or any other agreed upon rate), in accordance
with Dentist’s payment policies;
(ii)
Acknowledges that insurance limits do not apply to amounts that Dentist may
charge for such services or items;
(iii)
Acknowledges that supplemental insurance may elect not to make payments for
items and services covered by this contract
(iv)
Acknowledges that Patient has the right to have such services or items provided
by other dentists or practitioners for whom payment would be made under
Patient’s insurance.
(v)
Acknowledges that Pi Dental Center does not accept, submit or prepare medical
claims.
This contract shall remain in force and effect indefinitely from the date it is signed by Patient.
Accepted and Agreed: _____________________________
Dentist
Accepted and Agreed (Signature): _____________________________
Patient or Patient’s Legal Representative
Private Contract Opt Out – 2//2017