I, a duly registered medical practitioner/a duly registered oral and maxillofacial surgeon (strike out the inapplicable portion), apply to practise my profession in accordance with the Medical Services Payment Act and the regulations under that Act. In particular, I agree to accept payment by the Medicare Branch for any entitled service provided by me for which I submit an account to the Medicare Branch as payment in full for that service and I shall not make any further claim against any person with respect to that service.

(Where the participating medical practitioner or participating oral and maxillofacial surgeon is a corporation, this agreement must be signed by an authorized officer.)

I, a duly registered medical practitioner/a duly registered oral and maxillofacial surgeon (strike out the inapplicable portion), apply to practise my profession in accordance with the Medical Services Payment Act and the regulations under that Act. In particular, I agree to accept payment by the Medicare Branch for any entitled service provided by me for which I submit an account to the Medicare Branch as payment in full for that service and I shall not make any further claim against any person with respect to that service.

(Where the participating medical practitioner or participating oral and maxillofacial surgeon is a corporation, this agreement must be signed by an authorized officer.)

I, a duly registered medical practitioner/a duly registered oral and maxillofacial surgeon (strike out the inapplicable portion), apply to practise my profession in accordance with the Medical Services Payment Act and the regulations under that Act. In particular, I agree to accept payment by the Medicare Branch for any entitled service provided by me for which I submit an account to the Medicare Branch as payment in full for that service and I shall not make any further claim against any person with respect to that service.

(Where the participating medical practitioner or participating oral and maxillofacial surgeon is a corporation, this agreement must be signed by an authorized officer.)