Hanosh & Hunter Dental Group

Thank you for filling out our new patient form. Your information is important to us because we want to provide you with utmost safety and quality of care. Please make sure all information is accurate. Thank you!

Patient Info

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Send my appointment reminders via:
Please tell us where you heard about us (check all that apply):

Emergency Contact

Insurance Information

Primary Dental Insurance

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Secondary Dental Insurance

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Authorization
All of the above information is correct to the best of my knowledge. I authorize the use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Hanosh and Hunter Dental Group to act as my agent in helping me obtain payment from my insurance companies. I authorize payment to Hanosh and Hunter Dental Group. I permit a copy of this authorization to be used in place of the original. I give Hanosh and Hunter Dental Group, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.
Authorization Signature *
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Consent for Treatment

I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient.

Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care.
 
I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
 
I have read, understood, and agree to the above treatment policy.
Signature to consent to treatment. *
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Payment

Noce: Payment is due at the time of service unless alternative arrangements have been made in advance. Please choose a method of payment below. 

Payment In Full

Payment method (please choose one)
If using a credit card, please fill out the information below.
Your credit card information is kept on file for outstanding account balances.

Payment Plans

Start treatment immediately and pay over time with low monthly payments.
 
No-Interest Payment Plans
  • Pay for treatment over 6 or 12 months with NO interest.
  • As long as you pay the low minimum monthly payment each month when due, and the balance in full by the end of the promotional 6 or 12-month term, no interest will be charged on your purchase.
If you choose this option, you can fill out a CareCredit application at our office.
Payment Plan Type

Payment Policies

Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our office staff or clarification. 

For Patients with Dental Insurance

We accept dental insurance assignments, with the understanding that any uninsured portion not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms. Please note that although we strive to provide accurate information, such information is not a guarantee of payment or eligibility with your insurance company and is only an estimate. Your dental insurance plan is a contract between you, your employer, and the insurance company. Depending on your specific insurance plan, your dental insurance may not fully cover our office dental fees or the services we render. The difference between our office dental fees and your insurance reimbursement is your responsibility. 

Returned Checks

Personal checks that are returned due to "insufficient funds" are subject to a $25.00 service fee.

Service Charge

Payment is due at each appointment. I agree to pay any outstanding insurance balance within 60 days. If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $2.50 for a minimum balance of $25.00) which is an annual percentage rate of 18% applied to the last month's balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account balance or any future accounts. Please be advised that there is a $75.00-$125.00 fee charged for missed or broken appointments without 48 hours notice. To avoid this charge, kindly give us a minimum of 48 hours notice of any appointment cancellation. Feel free to contact us at any time with questions you may have.
Service Charge Signature *
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X-Ray/Records Release

There is a fee of $25.00 for any release of x-rays and/or records.

Minors

Adult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible or payment. This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may be denied unless charges have been pre-approved to a credit card or other payment arrangements have been made. 

Payment Authorization

I hereby authorize payment directly to Hanosh and Hunter Dental Group of the group insurance benefits otherwise payable to me. I understand that I am responsible or all costs of the above-named patient's dental treatment. The information on the page and the dental/medical histories are correct to the best of my knowledge. I grant the right to Hanosh and Hunter Dental Group to release the patient's dental and/or medical histories and other information about the patient's dental treatment to third-party payers and/or other health professionals. 
Payment Authorization Signature *
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Dental History

Previous Dentist

Dental Hygiene

Do you brush your teeth?
Do you floss?
Please check other dental hygiene aids that you use:
 

Dental Concerns

Check all that apply.
 
Does food tend to get caught between your teeth?
Do you hold foreign objects (pencil, pipe, pins, nails, fingernails, etc.) with your teeth?

Have you ever had:

Check all that apply.

Medical History

How is your general health?
Are you currently under medical treatment?
Do you require antibiotic pre-medication for your dental work?
Do we have permission to contact your doctor regarding your care?

Have you ever had:

Abnormal Bleeding
Allergies
Alzheimer/Dementia
Anaphylaxis
Anemia

Angina
Arthritis

Arteriosclerosis
Artificial Bones/Joints
Artificial Valves
Asthma

Autoimmune Disease
Birth Defects

Blood Disease
Blood Transfusions

Bruises Easily
Cancer
Chemotherapy
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Chest Pain

Chronic Fatigue Syndrome
Circulatory Problems
Cold Sores/Fever Blister
Congenital Heart Defect
Cortisone Medicine
Cough - Persistent or Bloody
Diabetes
Difficulty Breathing

Dizziness
Easily Winded

Emphysema
Epilepsy

Fainting
Frequent Diarrhea

Glaucoma
Gout


HIV/AIDS
Hearing Disorders

Heart Disease
Heart Attack

Heart Murmur
Heart Surgery

Head or Face Injury
Hemophilia

Hepatitis A
Hepatitis B

Hepatitis C
High Blood Pressure
History of substance abuse/drug addiction
Hives/Skin Rash
Hospitalized for any reason

Hyperglycemia
Hypotension (Low Blood Pressure)
Hypoglycemia
Irregular Heartbeat

Kidney Problems
Leukemia


Liver Problems
Lung Disease

Mitral Valve Prolapse
Nervous Disorder
Numbness of arms or hands
Osteoporosis

Pacemaker
Pain in the jaw or joints

Pneumonia
Psychiatric Problems
Radiation Treatments
Recent Weight Loss

Renal Dialysis
Rheumatic Fever

Rheumatism
Scarlet Fever

Seizures
Severe/Frequent Headaches
Sexually Transmitted Disease
Shingles

Shortness of Breath
Sickle Cell Anemia

Sinus Trouble
Spina Bifida
Stroke
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Swelling of Feet/Ankles
Swollen Neck Glands
Tattoos/Body Piercing

Thyroid Disease
Tonsillitis

Have you ever had an adverse reaction or allergies to any medication or substance?


Check all that apply.
 
Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate (Fosamax), clodronate (0stac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa).
Do you take or have you taken Phen-Fen or Redux?
Do you use marijuana?
Do you smoke or use tobacco?
Do you use alcohol?
Are you a recreational drug user?
Do you wear contact lenses?
Are you on a special diet?
Have you lost or gained more than 10 pounds in the past year?
Do you use more than two pillows to sleep?
Have you ever had any excessive bleeding requiring special treatment?
When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or feeling tired?
Have you been treated in a hospital in the last five years?
If female, please mark if you are:
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All of the information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you. 
By signing here you agree to the above paragraph and that all of the information in your medical history is accurate. *
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HIPPA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the following carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:
 
  • Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services.
  • Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
  • To Your Family and Friends: We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.
 
In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: 
 
  • When a state or federal law mandates that certain health information be reported for a specific purpose
  • For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
  • Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence
  • Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws
  • Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
  • Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations
  • Uses or disclosures for health-related research
  • Uses and disclosures to prevent a serious threat to health or safety
  • Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
  • Disclosures of de-identified information
  • Disclosures relating to worker's compensation programs
  • Disclosures of a "limited data set" for research, public health, or health care operations
  • Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
  • Disclosures to "business associations" who perform health care operations for our office and who commit to respect the privacy of your health information
 
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
 
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of May 25, 2017, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.
We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
If you think that we have not properly respected the privacy of your health information or that your privacy protections have been violated, you have the right to file a written complaint to us or the U.S. Department of Health and Human Sevices, Ofice or Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
For more information about HIPPA and/or to file a complaint, please call or visit our office or contact: 
 
The U.S. Department of Health & Human Sevices, Office or Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775

HIPPA Patient Consent Form

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPPA or The Healthcare Privacy Act). I understand that by signing this consent, I authorize Hanosh and Hunter Dental Group to use and/or disclose my protected health information to carry out the following: 
 
  • Treatment which includes direct and/or indirect treatment by other healthcare providers involved in my treatment.
  • Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
  • The day to day healthcare operations of your dental practice.
Additionally, I authorize you to share all my protected health information with the following individual(s):
 NameRelationshipPhone
Individual #1
Individual #2
Individual #3
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a complete description of the uses and disclosures of my protected personal health information, and my rights under HIPM. I understand that you reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected. 
HIPPA Patient Consent Form Signature *
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Dental Materials Fact Sheet

The Dental Board of California Dental Materials Fact Sheet Adopted by the Board on October 17, 2001. As required by Chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet Is Intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited or the patient's dental needs. It is not intended to be a complete guide to dental materials science. The most frequently used materials in restorative dentistry are amalgam, composite resin, glass ionomer cement, resin-ionomer cement, porcelain (ceramic), porcelain (fused-to-metal), gold alloys (noble) and nickel or cobalt-chrome (base-metal) alloys. Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors are compared in the attached matrix titled Comparisons of Restorative Dental Materials. A Glossary of Terms is also attached to assist the reader in understanding the terms used. The statements made are supported by relevant, credible dental research published mainly between 1993- 2001. In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993. The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made. The durability of any restoration is influenced by the dentist's technique when placing the restoration, the ancillary materials used in the procedure, and the patient's cooperation during the procedure. Following the restoration of the teeth, the longevity of the restoration will be strongly influenced by the patient's compliance with dental hygiene and home care, their diet, and chewing habits. Both the public and the dental profession are concerned about the safety of dental treatment and any potential health risks that might be associated with the materials used to restore the teeth. All materials commonly used (and listed in this fact sheet) have been shown through laboratory and clinical research, as well as through extensive clinical use to be safe and effective for the general population. The presence of these materials in the teeth does not cause adverse health problems or the majority of the population. There exist a diversity of various scientific opinions regarding the safety of mercury dental amalgams. The research literature in peer-reviewed scientific journals suggests that otherwise healthy women, children, and diabetics are not at increased risk for exposure to mercury from dental amalgams. Although there are various opinions with regard to mercury risk in pregnancy, diabetes, and children, these opinions are not scientifically conclusive and therefore the dentist may want to discuss these opinions with their patients. There is no research evidence that suggests pregnant women, diabetics and children are at increased health risk from dental amalgam fillings in their mouth. A recent study reported In the JADA factors in a reduced tolerance (1150th of the WHO safe limit) or exposure in calculating the amount of mercury that might be taken in from dental fillings. This level falls below the established safe limits for exposure to a low concentration of mercury or any other released component from a dental restorative material. Thus, while these subpopulations may be perceived to be at increased health risk from exposure to dental restorative materials, the scientific evidence does not support that claim. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to selected materials. As with all dental materials, the risks and benefits should be discussed with the patient, especially with those in susceptible populations. There are differences between dental materials and the individual elements or components that compose these materials. 
For example, dental amalgam filling material is composed mainly of mercury (43-54%) and varying percentages of silver, tin, and copper (46-57%). It should be noted that elemental mercury is listed on the Proposition 65 list of known toxins and carcinogens. Like all materials in our environment, each of these elements by themselves is toxic at some level of concentration if they are taken into the body. When they are mixed together, they react chemically to form a crystalline metal alloy. Small amounts of free mercury may be released from amalgam fillings over time and can be detected in bodily fluids and expired air. The question is whether any free mercury is present importin sufficient levels to pose a health risk. Toxicity of any substance is related to dose, and doses of mercury or any other element that may be released from dental amalgam fillings fall far below the established safe levels as Stated in the 1999 US Health and Human Sevice Toxicological Profile or Mercury Update. All dental restorative materials (as well as all materials that we come in contact within our daily life) have the potential to elicit allergic reactions in hypersensitive individuals. 1 These must be assessed on a case-by-case basis, and susceptible Individuals should avoid contact with allergenic materials. Documented reports of allergic reactions to dental amalgam exist (usually manifested by transient skin rashes in individuals who have come into contact with the material), but they are atypical. Documented reports of toxicity to dental amalgam exist, but they are rare. There have been anecdotal reports of toxicity to dental amalgam and as with all dental material risks and benefits of dental amalgam should be discussed with the patient, especially with those in susceptible populations. Composite resins are the preferred alternative to amalgam in many cases. They have a long history of biocompatibility and safety. Composite resins are composed of a variety of complex Inorganic and organic compounds, any of which might provoke an allergic response in susceptible individuals. Reports of such sensitivity are atypical. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to composite resin restorations. The risks and benefits of all dental materials should be discussed with the Patient, especially with those in susceptible populations. Other dental materials that have elicited significant concern among dentists are nickel-chromium-beryllium alloys used predominantly or crowns and bridges. Approximately 10% of the female population is alleged to be allergic to nickel. 2 The incidence of allergic response to dental restorations made from nickel alloys is surprisingly rare. However, when a patient has a positive history of confirmed nickel allergy, or when such hypersensitivity to dental restorations is suspected, alternative metal alloys may be used. Discussion with the patient of the risks and benefits of these materials is indicated. Dental Amalgam: A scientific review and recommended public health service strategy for research, education and regulation, Dept of Health and Human Sevices, Public Health Sevice, January 1993.2 Merck Index 1983. Tenth Edition, M Marsha Windhol, Z (ed). I acknowledge that I have received and read The Dental Material Facts Sheet from The Dental Board of California dated October 2001 as provided by Hanosh and Hunter Dental Group. 
Dental Materials Fact Sheet *
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Release of Records

To Whom It May Concern: Please release all my dental records and/or x-rays via email (preferred) or regular mail to/from Hanosh and Hunter Dental Group at the following address: info@hanoshandhunter.com 6072 Skymeadow Way Paradise, CA. 95969 (530) 877-9800 (530) 877-9811 -fax *
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Cell Phone Communication

I consent to the dental office of Hanosh and Hunter Dental Group using my cell phone number to (choose one or both)
Cell Phone Communication Signature *
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Medicare Opt-Out Contract

MEDICARE PRIVATE CONTRACT "OPT-OUT" AFFIDAVIT I, George Scott Hanosh, DDS, Inc. /G. Scot Hanosh, DDS, Inc., and/or Gregory Beau Hunter, DDS, Inc. /G. Beau Hunter, DDS, attest that under the penalty of perjury the following is true and correct to the best of my knowledge, information and belief: Except for emergency or urgent care services (specified in 42 C.F.R. 405.440), during the opt-out period, I will provide services to Medicare beneficiaries only through private contracts that meet the criteria of paragraph 42 C.F.R. 405.415 or services that, but for their provision under a private contract, would have been Medicare covered services. I will not submit a claim to Medicare or any item or service furnished to any Medicare beneficiary during the two-year period beginning on the following effective date: January 30, 2016 (the "opt out period"), nor will 1, or any entity acting on my behalf, submit a claim to Medicare or services furnished to a Medicare beneficiary during this two-year period, except as specified in 42 C.F.R. 405.440. I understand that during the opt-out period, I may receive no direct or indirect Medicare payment or services that !furnish to Medicare beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare Advantage (formerly called Medicare Choice) plan. I acknowledge that, during the opt-out period, my services are not covered under Medicare and no Medicare payment may be made to any entity or my services, directly or on a capitated basis. I promise that, during the opt-out period, I will be bound by the terms of both this affidavit and the private contract(s) into which I have entered with a Medicare beneficiary. I acknowledge that the terms of this affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by me during the opt-out period (except for emergency or urgent care services furnished to the beneficiaries with whom I have not previously privately contracted ) without regard to any payment arrangements I may make. I have signed a Pat B participation agreement, and I acknowledge that such agreement terminates on the effective date of this affidavit. (This provision is not required or physicians who have not signed a Medicare Part B participation agreement.) I understand that a beneficiary who has not entered into a private contract and who requires emergency or urgent care services may not be asked to enter into a private contract with respect to receiving such services and that the rules of 42
C.F.R. 405.440 apply if I furnish such services. I understand that I must file this affidavit with all carriers who have jurisdiction over claims that I would otherwise file with Medicare and that this affidavit must be filed no later than ten days after the first private contract to which this affidavit applies is entered into. 1134143373 -G. Scott Hanosh, DDS, Inc. National Provider Identifier (NPI) 1326323270 - G. Beau Hunter, DDS, Inc. National Provider Identifier (NPI)
Medicare Opt-Out Contract Signature *
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