1 Anthony J. Hornaday, D.D.S.
2 Oral and Maxillofacial Surgery of East Central Indiana
3 620 S. Tillotson Avenue Muncie, IN 47304 ♦ ♦ (765) 289-9705
4 Office Financial Policy
5 1.  If the patient does not have insurance, full payment is required at the time of surgery.
6 2.  If you are having a single tooth removed, the entire fee (which we will provide you with prior to your services) will be due the day
7 of the extraction. We will file your insurance claim for you and will reimburse you if any payment is made by your insurance
8 company.
9 3.  If the patient does have insurance, we do require a percentage of the total fee to be paid at the time services are rendered which is
10 an ESTIMATE of your out of pocket expense. There may be an additional amount due after your insurance pays.
11 4.  We are not responsible for benefits quoted to us by your insurance company whether this was received over the phone or if we
12 have received a written predetermination on your behalf. Insurance companies will not guarantee coverage and/or payment to us
13 until they receive an actual claim; therefore, regardless of the information that was given to us by your insurance company, either
14 verbally or in writing, you may still be responsible for the entire fee for your treatment charged by this office.
15 5.  We will file claims to all insurance companies, however, the ONLY insurance companies that Dr.  Hornaday is contracted with are
16 Guardian, Delta Dental Premier dental insurance and Medicaid. Regardless of insurance coverage, the patient, or patient’s legal
17 guardian, is ultimately responsible for all fees charged by this office.
18 6.  Sixty days will be allowed for your insurance company to process and pay your claim.  If, after sixty days, no notice has been
19 received from your insurance company, it is your responsibility to contact them directly and the entire balance is your responsibility
20 at that time.
21 7.  If your insurance requires a predetermination prior to the procedure, it is the patient’s (or patient’s legal guardian’s/Power of
22 Attorney’s) responsibility to notify our office.
23 8.  The parent (or legal guardian) that accompanies a minor to the office will be responsible for all fees charged.  We cannot and will
24 not contact someone who was not present in our office to ask for payment, such as in a divorce situation.
25 9.  Should your account become past due, you will be responsible to pay all collection costs, including collection agency fees,
26 attorney fees, and all court costs. These fees will be added to your balance and this new amount will be placed with our collection
27 agency and become your responsibility to pay.
28 10.  Please note that if any portion of your care is rendered at IU Health Ball Memorial Hospital (in-patient or out-patient), there will
29 be separate charges from the hospital that may or may not be fully covered by your insurance. Dr. Hornaday is not financially
30 affiliated with the hospital and is not responsible for and has no knowledge of these charges. It is your responsibility to check with
31 your insurance to see what will or will not be covered.
32 11.  This signature is on file as my authorization for the release of information necessary to process my claim and collect monies
33 owed. I hereby authorize payment directly to Dr. Anthony Hornaday of the insurance benefits otherwise due me. I certify that I am
34 the legal guardian and/or power of attorney of the patient listed on this form. I have read the above financial policy and agree to all of
35 the terms therein.
36 Patient________________________________ Patient’s Signature ________________________________Date _______________
37 Parent or Legal Guardian Signature ________________________________________________________Date _______________
38 Witnessed By __________________________________________________________________________Date _______________
39 Patient Information
40 Anthony J. Hornaday, D.D.S.
41 Oral and Maxillofacial Surgery
42 Dr. Mr. Mrs. Ms. Miss ___________________________________________________________________________________________________
43 First Middle Last Nickname
44 Address: _______________________________________________________ City/State: ___________________________ Zip: ________________
45 Home Tel #: ________________________________ Work Tel #: _______________________________ Cell #: ____________________________
46 Date of Birth: _______/_______/_______ Age: _______ Sex: Male Female Marital Status: Single Married Widowed Divorced
47 Soc Sec. #: ___________________________________ Pharmacy:______________________________________________________________
48 Employer: _______________________________________________ Occupation: ____________________________________________________
49 Patient’s Dentist: _____________________________ Physician: ___________________________ Orthodontist: __________________________
50 Who referred you to our office? Dentist Physician Orthodontist Friend ___________________ Other____________________
51 Have you or any member of your family been a patient in our office before? Yes No When? (Year): _____________________________
52 Who?: ______________________________________________ Relationship to patient: ______________________________________
53 If patient is a full-time student, name of school: _________________________________________________________________________________
54 Emergency Contact: ______________________________________________ Daytime phone #: ________________________________________
55 Relationship to patient: ____________________________________
56 Person Responsible for Payment (if different from above)
57 Person Responsible for Payment: ____________________________________________________________________________________________
58 Address: _____________________________________________________ City/State: __________________________ Zip: ___________________
59 DOB: _______/_______/_______ Soc Sec #: __________________________________
60 Home Phone: ______________________________ Work Phone: ____________________________ Cell Phone: __________________________
61 I understand in signing this statement that I am financially responsible to Dr. Anthony J. Hornaday for all fees incurred and all costs of collection:
62 including but not limited to service, collection, collection agency, and attorney fees.
63 If your insurance company does not pay your claim as expected, the responsible party is obligated for the balance of the account. I hereby authorize the
64 insured’s insurance company to pay directly to Dr. Anthony J. Hornaday any and all of the benefits otherwise payable to me or the patient.
65 Signature of Party Responsible for Payment: ________________________________________ Relationship to Patient: ________________________
66 Print Name: __________________________________________________________________
67 DENTAL Insurance Coverage Information (If you have additional coverage, please request an additional form)
68 Primary Dental Insurance Name of Insurance Company: _______________________________________
69 Subscriber Name: _________________________________________ DOB: _______/_______/_______ Insured’s Daytime Phone #: ____________________
70 Subscriber Address: _______________________________________________________________Plan ID (If other than SS#): ________________________________
71 Subscriber Soc Sec #: ______________________________________ Group #: _____________________ Employer Name: ____________________________
72 Relationship to Patient: _____________________________________ Insurance Co. Phone: ______________________________________________________
73 Insurance Co. Address: ___________________________________________________________________________________________________________________
74 MEDICAL Insurance Coverage Information (If you have additional coverage, please request an additional form)
75 Primary Medical Insurance Name of Insurance Company: ________________________________________
76 Subscriber Name: _________________________________________ DOB: _______/_______/_______ Insured’s Daytime Phone #: ____________________
77 Subscriber Address: _______________________________________________________________Plan ID (If other than SS#): ________________________________
78 Subscriber Soc Sec #: ______________________________________ Group #: _____________________ Employer Name: ____________________________
79 Relationship to Patient: _____________________________________ Insurance Co. Phone: ______________________________________________________
80 Insurance Co. Address: ___________________________________________________________________________________________________________________
81 I certify all information is true, correct, and complete and authorize the release of health care information for the purpose of evaluating and
82 administering claims for benefits. I authorize payment of medical/dental benefits to Dr. Hornaday and accept full financial responsibility
83 regardless of insurance coverage. I also certify that I am the legal guardian of the patient listed on this form.
84 Signed: _____________________________________________ ___________________________ Date: _____________
85 Patient or Legal Guardian Signature Relationship to Patient
86 Print Name: _________________________________________________________________________________________________
87 Patient Information
88 Anthony J. Hornaday, D.D.S.
89 Oral and Maxillofacial Surgery
90 Patient Name: ____________________________________________________________________________________________________________
91 First Middle Last Nickname
92 Reason for today’s office visit: ______________________________________________________________________________________________
93 Height: __________ Weight: ___________ Age: __________ Yes No Notes
94 Have there been any changes in your general health in the past year?...............................> [ ] [ ]
95 Are you under the care of a physician?...............................................................................> [ ] [ ]
96 For what? ______________________________________________________
97 Have you ever been hospitalized or undergone any surgery?.............................................> [ ] [ ]
98 Please explain: __________________________________________________
99 Please indicate if you have ever had any of the following conditions:
100 Yes No Notes Yes No Notes
101 Heart Disease Anemia
102 Chest Pain Bleeding Problems
103 Heart Attack Sickle Cell Anemia
104 Bypass Stomach Ulcer
105 Angioplasty HIV or AIDS
106 Heart Murmur Cancer or Tumors
107 Mitral Valve Prolapse Radiation/Chemotherapy
108 Rheumatic Fever Liver Disease
109 High Blood Pressure Hepatitis or Jaundice
110 Artificial Heart Valve Diabetes
111 Pacemaker Thyroid Disease
112 Stroke Kidney Disease
113 Glaucoma Arthritis
114 Asthma Artificial Joints
115 Lung Disease Seizures (epilepsy)
116 Tuberculosis Illicit (Illegal) Drug Use
117 Shortness of Breath Alcohol/Drug Abuse
118 Swollen Ankles Psychiatric Disorder
119 Yes No
120 · Are you currently taking any drugs or medications?...............................................................................> [ ] [ ]
121 Please List: __________________________________________________________________
122 __________________________________________________________________
123 · Have you ever had any adverse reaction to local or general anesthetic?.................................................> [ ] [ ]
124 · Are you allergic to anything?...................................................................................................................> [ ] [ ]
125 Please List: __________________________________________________________________
126 · Have you ever been treated or are you taking medicine for osteoporosis?..............................................> [ ] [ ]
127 · Have you ever been prescribed any bisphosphonate medications such as:
128 Fosamax, Aredia, Zometa, Actonel, Boniva?.........................................................................................> [ ] [ ]
129 · Is this visit a result of an accident?...........................................................................................................> [ ] [ ]
130 If yes, date of accident and describe: ______________________________________________
131 ____________________________________________________________________________
132 · Do you smoke?.........................................................................................................................................> [ ] [ ]
133 · Women: Are you pregnant?......................................................................................................................> [ ] [ ]
134 Are you nursing?.........................................................................................................................> [ ] [ ]
135 Do you take birth control?..........................................................................................................> [ ] [ ]
136 · Do you have any other medical conditions not listed above?...................................................................> [ ] [ ]
137 Please List:__________________________________________________________________
138 __________________________________________________________________
139 I certify all above information is true, correct, and complete and authorize the release of health care information for the purpose of
140 evaluating and administering claims for benefits. I authorize payment of medical/dental benefits to Dr. Hornaday and accept full financial
141 responsibility regardless of insurance coverage. If I am not the patient listed on this form, I certify that I am the legal guardian/health care
142 representative of the patient listed on this form and have legal authority to make healthcare decisions for this patient.
143 Signed: _____________________________________________ ___________________________ Date: _____________
144 Patient or Legal Guardian Signature Relationship to Patient
145 Print Name: _________________________________________________________________________________________________
146 Patient Information
147 Anthony J. Hornaday, D.D.S.
148 Oral and Maxillofacial Surgery
149 The following several paragraphs pertain to all Oral and Maxillofacial Surgery procedures.
150 I realize the importance of supplying true and accurate information about my health, especially concerning possible
151 pregnancy, allergies, medications, and history of drug or alcohol abuse. I understand that if I misinform my doctor
152 the consequences may be life threatening or otherwise adversely affect the results of my surgery.
153 While performing my surgery I recognize that Dr. Hornaday may discover other or different conditions than
154 expected. This may require different or additional procedures than those planned or may require termination of my
155 surgery. I authorize Dr. Hornaday to perform such other procedures as he deems medically and/or surgically
156 necessary in his professional judgment or to stop my procedure.
157 I consent to the administration of anesthetics and medications as may be deemed necessary or advisable for my
158 comfort, health, and safety. If general anesthesia is used, I understand that there may be soreness, redness, swelling,
159 and/or bruising at or around the IV site or along the vein that may require additional treatment. Other rare
160 complications of IV anesthesia may include allergic reaction to medications, respiratory problems that may require a
161 breathing tube be placed, stroke, heart attack, heart failure, and/or death.
162 I am also aware that oral sedation, intravenous (IV) sedation, general anesthesia, and many drugs are not
163 recommended for use for women who are pregnant. I understand that it is my responsibility (or the responsibility of
164 a parent or legal guardian of a female patient) to advise Dr. Hornaday if I am pregnant or possibly could be
165 pregnant.
166 I also have been informed by Dr. Hornaday that antibiotics can and may interfere with the effectiveness of birth
167 control and that I can and may become pregnant if another form of contraception is not used. I also understand and
168 have been informed that if antibiotics are used in my care I will need to use another form of contraception and
169 should consult my medical doctor.
170 I understand that there are two Oral Surgeons at this office, Dr. Anthony J. Hornaday and Dr. James E. Hornaday. I
171 understand that the procedure may be performed by either doctor and I give my consent for the procedure to be
172 performed by either doctor.
173 I have been made aware that certain medications, drugs, anesthetics and prescriptions that I may be given can cause
174 drowsiness, and lack of awareness and coordination which also may be increased by the use of alcohol and other
175 drugs. I understand that I should not use alcohol, operate a vehicle or other hazardous machinery, or make any legal
176 decisions while under the influence of any medication, anesthesia, or prescription given by this office. I have been
177 advised not to return to work while taking such medications, or until fully recovered from the effects of such
178 medications, drugs, anesthetics and/or prescriptions. I understand this recovery may take up to 24 hours or more
179 after I have taken the last dose of medication. If I am given sedative medication for my surgery, I agree not to drive
180 myself to the appointment or home afterwards and will have a responsible adult drive me to the appointment and
181 home and accompany me until I am fully recovered from the effects of the sedation.
182 I certify that I have read and fully understand the terms and words in the above consent and /or any verbal
183 explanations given to me by my doctor and/or his assistants, and that I give my consent voluntarily. If I am not the
184 patient listed on this form, I certify that I am the legal guardian/health care representative of the patient listed on
185 this form and have legal authority to make healthcare decisions for this patient.
186 Patient_______________________________ Patient’s Signature ________________________________ Date _______________
187 Parent or Legal Guardian Signature _______________________________________________________ Date _______________
188 Witnessed By _________________________________________________________________________ Date _______________
189 Anthony J. Hornaday, D.D.S.
190 Oral and Maxillofacial Surgery
191 Information Regarding Pain Clinics, Pain Contracts, and Controlled Substances
192 Patient Name: ____________________________________________________________________________________________________________
193 First Middle Last Nickname
194 Date of Birth: _______/_______/_______ Age: _______ Sex: Male Female
195 1.  Are you currently, or have you ever been, under a pain contract?
196 If so, with whom?
197 2.  Are you currently receiving narcotic medications (i.e.  Ultram, Tramadol, Norco, Vicodin, Lortab, Lorcet,
198 Hyrdocodone, Percocet, Oxycodone, OxyContin, MS Contin, Fentanyl, Fentanyl Patch, Morphine, Dilaudid...)?
199 If so, please list:
200 3.  Are you currently being treated for, or have you ever been treated for, narcotic or any substance abuse?
201 If so, please explain:
202 4.  Are you currently taking, or have you ever taken, medications such as Suboxone or Methadone?
203 If so, please explain:
204 Please note that this office does routinely use INSPECT; an INSPECT report summarizes the controlled substances
205 a patient has been prescribed, the quantity of medication, the date the medication was prescribed/filled, the
206 practitioner who prescribed them, and the dispensing pharmacy where the patient obtained them.
207 Falsifying information regarding your controlled substance use and/or pain clinic/pain contract involvement can
208 have adverse health effects leading to serious complications, hospitalization, and even death. Falsifying this
209 information or not being completely honest with regards to this information will result in cancellation of your
210 appointment and permanent dismissal from this office and may also result in dismissal by your pain
211 clinic/doctor and no further prescriptions being dispensed to you.
212 Patient_______________________________ Patient’s Signature ________________________________ Date _______________
213 Parent or Legal Guardian Signature _______________________________________________________ Date _______________
214 Witnessed By __________________________________________________________________________ Date ______________
215 Anthony J. Hornaday, D.D.S.
216 Oral and Maxillofacial Surgery of East Central Indiana
217 620 S. Tillotson Avenue ¨ Muncie, IN 47304 ¨ (765) 289-9705
219 Patient Name: Date:
220 It is required that all patients read and sign consent prior to any treatment. In order for you to give your consent to
221 treatment we feel strongly that you, as the patient, should be given as much information as possible regarding that
222 treatment. We have found that our best patients are our most informed patients. This information is not meant to
223 alarm you, but rather allow you to make an informed decision. We also feel that you should have an opportunity
224 to ask questions and receive satisfactory answers to those questions. We ask that you please take your time and
225 read the following form completely.
226 Extraction of teeth is an irreversible process, and whether routine or difficult, is a surgical procedure. As in any
227 surgery, there are some potential risks and complications. These include, but are not limited to, the following:
228 1.  Swelling, bruising and/or discomfort.
229 2.  Stretching of the corners of the mouth resulting in cracking or bruising.
230 3.  Possible infection requiring additional treatment, including hospitalization.
231 4.  Injury to nerves: In the lower jaw there is a nerve canal for a nerve (inferior alveolar nerve) that supplies
232 feeling to the lower lip, chin, tongue, teeth, gingiva (gums), and cheek. There is also a nerve (lingual nerve)
233 that lies outside the lower jaw that supplies feeling to the tongue. There is a possibility that these nerves
234 could be bumped, bruised, cut, or damaged during the removal of lower teeth, especially 3rd molars
235 (wisdom teeth). If injury were to occur to any one of the previously mentioned nerves, numbness of the
236 lower lip, chin, tongue, teeth, gingiva (gums), and/or cheek could occur. Injury to these nerves can also
237 cause pain (dysesthesia) which can persist indefinitely. Injury to these nerves and the above listed
238 symptoms can also be caused by the local anesthetic injection even if no teeth are removed and no surgery
239 performed. Usually, injury from the removal of teeth and/or the injection is temporary, but it could be
240 permanent. Numbness of the tongue would also result in loss of taste.
241 5.  Dry socket (Alveolar Osteitis) – failure of a normal blood clot to form in the extraction site causing jaw pain,
242 usually requiring additional care.
243 6.  Possible damage to adjacent teeth, especially those with large fillings or crowns, requiring replacement of
244 the filling or crown, extraction, or root canal therapy of the tooth/teeth involved.
245 7.  Injury to the temporomandibular joint (TMJ): Removal of teeth may produce pain, clicking, and/or
246 limitation of motion (trismus). If you have a preexisting TMJ disorder Dr. Hornaday should be notified
247 before surgery. Removal of teeth can aggravate a preexisting problem with your TMJ even with the gentlest
248 of care. If a problem with your TMJ should occur further treatment may be necessary.
249 8.Heavy bleeding.  This may require hospitalization and/or a general anesthetic to resolve.
250 Patient_____________________________ Patient’s Signature _______________________________ Date _______________
251 Parent/Legal Guardian/POA Signature ________________________________________________ Date _______________
252 Witnessed By _______________________________________________________________________ Date _______________
254 9.  Sharp ridges or bone splinters may form later at the edge of the socket.  These usually require another
255 surgery to smooth or remove.
256 10.  Incomplete removal of tooth fragments: to avoid injury to vital structures such as nerves, vessels, or sinus,
257 tooth roots may be left in place. Rarely, these fragments of tooth may require an additional procedure to
258 remove if they become infected.
259 11.  Sinus involvement: the roots of upper back teeth are often close to the maxillary (upper jaw) sinus and
260 sometimes a piece of the root or entire tooth can be displaced into the sinus which would require additional
261 surgery and/or hospitalization. An opening from the mouth into the maxillary sinus and/or an infection can
262 occur which may require additional surgical procedure(s) and/or hospitalization.
263 12.  Displacement of an upper tooth into a space behind the upper jaw called the infratemporal fossa.  This may
264 require hospitalization and a general anesthetic to remove.
265 13.  Jaw fracture - while quite rare, it is possible with removal of impacted teeth or in people with atrophic
266 (small) mandibles (lower jaw). This would require wiring the jaws together and/or hospitalization for an
267 open reduction and internal fixation (application of plates and screws) of the jaw.
268 14.  Nausea and/or vomiting, usually due to medications
269 15.  Accidental swallowing of a tooth, filling, or other foreign material that may require X-Rays at the hospital to
270 determine where the material lodged. Additional procedures and/or general anesthetic may be required to
271 remove the object.
272 16.  I understand when teeth are removed that a space is created.  I understand that adjacent teeth either next to
273 or opposing the space may migrate or supererupt into the space which may lead to their removal also if
274 nothing is done to replace the extracted teeth.
275 17.  I understand that no warranties or guarantees of any kind have been made to me or anyone about the results
276 of my surgery or procedure(s). I have been given adequate opportunity to read this entire form and to ask
277 any questions about my surgery or procedure(s) before signing this form. I understand that it is my
278 responsibility to inform my doctor if I wish to try another method of treatment to keep my tooth/teeth rather
279 than undergo surgical intervention. I have been informed of the reason for my surgery, the risks involved,
280 and possible alternate methods of treatment, if any, and I elect to undergo the treatment Dr. Hornaday has
281 proposed.
282 18.  I understand and agree that this consent form is valid for all future procedures unless the content changes,
283 at which time I will be given an updated consent form.
284 I certify that I have read and fully understand the terms and words in the above consent and /or any verbal
285 explanations given to me by my doctor and/or his assistants, and that I give my consent voluntarily. If I am not the
286 patient listed on this form, I certify that I am the legal guardian/health care representative of the patient listed on
287 this form and have legal authority to make healthcare decisions for this patient.
288 Patient___________________________ Patient’s Signature ________________________________ Date _______________
289 Parent/Legal Guardian/POA Signature ________________________________________________ Date _______________
290 Witnessed By ______________________________________________________________________ Date _______________
291 Anthony J. Hornaday, D.D.S.
292 Oral and Maxillofacial Surgery of East Central Indiana
293 620 S. Tillotson Avenue ¨ Muncie, IN 47304 ¨ (765) 289-9705
294 Medical/Protected Health Information Release Form
295 (HIPAA Release Form)
296 Name: _______________________________________ Date of Birth: ______/______/_______
297 Release of Information
298 [ ] I authorize the release of my medical and protected health information from
299 Anthony J. Hornaday, D.D.S. including all medical records, diagnoses, examination/test
300 results, treatment, appointment times and information, claims information, and fees
301 charged.
302 This information may be released to:
303 [ ] Spouse_________________________________________________________
304 [ ] Children________________________________________________________
305 [ ] Other__________________________________________________________
306 [ ] Information is not to be released to anyone.
307 This Release of Information will remain in effect until terminated by me in writing.
308 Messages
309 Please call: [ ] my home [ ] my work [ ] my cell Number: __________________
310 If unable to reach me:
311 [ ] You may leave a detailed message
312 [ ] Please leave a message asking me to return your call
313 Signed: ______________________________________ Date: ____/____/_____
314 Witness: ______________________________________ Date: ___/____/______
315 Acknowledgment of Receipt of Notice of Privacy Practices
316 Anthony J. Hornaday, D.D.S.
317 * You May Refuse to Sign This Acknowledgment*
318 I have received a copy of this office’s Notice of Privacy Practices.
319 Print Name:____________________________________________________________________
320 Signature:_____________________________________________________________________
321 Date:_________________________________________________________________________
322 For Office Use Only
323 ______________________________________________________________________________________________
324 We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment
325 could not be obtained because:
326 o Individual refused to sign
327 o Communications barriers prohibited obtaining the acknowledgment
328 o An emergency situation prevented us from obtaining acknowledgment
329 o Other (Please Specify)
330 Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval
331 of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or
332 state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to
333 HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.
334 © 2010, 2013 American Dental Association. All Rights Reserved.
335 Medicare Private Contract
336 for the Patients of Anthony J. Hornaday, D.D.S.
337 This Medicare Private Contract (“Agreement”) dated as of _________ _____ 20___, (“Effective Date”) is
338 made by and between Anthony J. Hornaday, D.D.S., (“Dr. Hornaday”) whose principal office is located at 620 S. Tillotson
339 Ave., Muncie, IN 47304, and _________________________________, (“you” or “the beneficiary, or his or her legal
340 representative,”), who resides at (your address).
341 1.  Explanation.  Dr.  Hornaday is no longer a participating physician with Medicare under the Social Security Act.
342 This document explains Dr. Hornaday’s rights and obligations as your physician, and your rights and obligations as Dr.
343 Hornaday’s patient. This contract is specifically limited to the financial agreement between you and Dr. Hornaday and does not
344 obligate you or Dr. Hornaday to a specific medical treatment. A change in the Social Security Act, effective January 1, 1998,
345 permits physicians and their Medicare patients, or their legal representatives, to enter into private written contracts regarding
346 benefits. Beneficiaries, or their legal representatives, and physicians who take advantage of these private written contracts are
347 not allowed to submit claims to Medicare, or to expect payment from Medicare. This applies only when you have a written
348 private contract with a physician. It does not apply for other physicians that you see, unless you enter into a similar contract
349 with those physicians.
350 You are not required to enter into a private contract with Dr. Hornaday, or with any physician that does not participate in
351 the Medicare program. If you wish to continue to have your medical services paid under your Part B Medicare coverage, do
352 not sign this agreement and transfer your care to another physician that is participating in the Medicare Part B program.
353 2.  Beneficiary Status.  You are a beneficiary currently enrolled in Medicare Part B or a beneficiary that may
354 become enrolled in Medicare in the future. If you are not currently a Medicare beneficiary, this Agreement is
355 applicable to you only upon your enrollment in Medicare.
356 3.  Dr.  Hornaday’s Status.  Dr.  Hornaday has not been excluded from providing Medicare services.  Dr.
357 Hornaday has personally decided not to participate in Medicare.
358 4.  Dr.  Hornaday’s Obligations.
359 a) Dr. Hornaday will provide medical treatment to you that you have agreed to receive.
360 b) Dr. Hornaday will not submit any claims to Medicare for any items or medical services that he provides,
361 even if they are covered by Medicare.
362 c) Dr. Hornaday will not execute this Agreement when you are facing a medical emergency or urgent
363 health care situation.
364 d) Dr. Hornaday will provide you with a copy of this Agreement before he provides medical services to
365 you.
366 e) If the Centers for Medicare and Medicaid Services ("CMS") request a copy of this document, Dr.
367 Hornaday will provide a copy to CMS.
368 5.  Beneficiary Obligations.
369 a) The beneficiary, or his or her legal representative, agrees to be fully responsible for payment of all items
370 or services furnished by Dr. Hornaday. The beneficiary, or his or her legal representative, understands
371 that no Medicare reimbursement will be available for Dr. Hornaday’s services or any items furnished by
372 him.
373 b) The beneficiary, or his or her legal representative, and Dr. Hornaday agree that limits under the
374 Medicare program do not apply to amounts which Dr. Hornaday may charge the beneficiary, or his or
375 her legal representative.
376 c) The beneficiary, or his or her legal representative, agrees not to submit a claim to Medicare and agrees
377 not to ask Dr. Hornaday to submit a claim to Medicare for services provided to the beneficiary.
378 d) The beneficiary, or his or her legal representative, understands that due to this private contract, Medicare
379 payment will not be made for any items or services furnished by Dr. Hornaday. This applies to services
380 which normally would be reimbursable under Medicare if this Agreement were not in place.
381 e) The beneficiary, or his or her legal representative, understands that this contract pertains to Dr.
382 Hornaday’s services only and that Medicare covered medical services may be obtained from other
383 physicians who have not opted out of Medicare. This contract does not apply to relationships which the
384 beneficiary, or his or her legal representative, has with other physicians.
385 f) Medigap plans under Section 1882 of the Social Security Act will not pay for services or items provided
386 by Dr. Hornaday, since they are not covered by Medicare. It is also possible that other supplemental
387 insurance plans may not pay for services or items provided by Dr. Hornaday, since they are not covered
388 by Medicare.
389 6.  Term and Termination.  This document shall begin as of the Effective Date and be effective for one (1) year
390 from the Effective Date (the "Initial Term"). AT THE CONCLUSION OF THE INITIAL TERM OF THIS AGREEMENT,
393 PERIODS (each, a "Renewal Term"). This Agreement shall automatically terminate upon the first to occur of the following:
394 (1) Dr. Hornaday’s election to participate in the Medicare program; (ii) in the event that Dr. Hornaday or the beneficiary, or his
395 or her legal representative, violate any of the items set forth herein; or (iii) upon thirty (30) days prior written notice from one
396 party to the other party; provided, however, that all amounts owned for items or services provided prior to the termination of
397 this Agreement are the responsibility of the beneficiary, or his or her legal representative.
398 7.  Indemnification and Successors and Assigns.  The parties agree that this Agreement shall be fully binding
399 upon their successors and assigns and that the beneficiary, or his or her legal representative, will indemnify and defend Dr.
400 Hornaday against any claims, losses, liabilities or costs incurred as a result of any services provided to the beneficiary, or his or
401 her legal representative, under this Agreement.
402 IN WITNESS WHEREOF, the parties hereto have duly executed this Agreement as of the Effective Date first written above.
403 Anthony J. Hornaday, D.D.S.
404 Name of Provider
405 Signature of Provider
406 620 S. Tillotson Ave., Muncie, IN 47304
407 Principal Office Address
408 1407897523
409 National Provider Identifier (NPI)
410 Name of Beneficiary
411 Signature of Beneficiary
412 Beneficiary's Legal Representative
413 Beneficiary's Legal Representative's Signature