Non-Participating Medicare/Medicaid Provider of Services If you would like to print and fill out a PDF version of this form please click here. Otherwise fill out the form below. NON-PARTICIPATING MEDICARE/MEDICAID PROVIDER OF SERVICES(Required) I agree and am aware of the following.I have been informed that Dr. James J. Gift, DDS, M.S. has opted out of the Medicare/Medicaid program(s). I am aware that any services included but not limited to exams, x-ray, surgical procedures, prescriptions, and laboratory procedures provided by Dr. James J. Gift, DDS, M.S. cannot be filed with Medicare/Medicaid for reimbursement. I do have the option of seeing a Medicare/Medicaid provider for the services(s) in question but I choose to obtain treatment from Dr. James J. Gift, DDS, M.S.Patient First Name(Required) Patient Last Name(Required) Phone(Required)Email(Required) Name Of Person Signing If Other Than Patient First Last