Non-Participating Medicare/Medicaid Provider of Services

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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)

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Name Of Person Signing If Other Than Patient

First Last

James J. Gift D.D.S, M.S – Board Certified Oral Maxillofacial Surgeon

Florida Facial Surgery Center

James J. Gift D.D.S, M.S.

Board Certified Oral Maxillofacial Surgeon

Non-Participating Medicare/Medicaid Provider of Services