• Advance Beneficiary Notice of Noncoverage (ABN)

  •  

    The attached Advance Beneficiary Notice of Noncoverage (“ABN”) is given to certain Medicare beneficiaries (“Recipients”) to advise Recipients that Medicare may not provide coverage for the treatment specified on the ABN.

    The ABN is a written notice that provides you with an opportunity to accept or refuse the items or services listed on the ABN, and protects you from unexpected financial liability in cases where Medicare denies payment. Pursuant to our Patient Financial Policies, you are required to pay in full for any services for which Medicare denies payment. You have the right to appeal Medicare’s decision in the event Medicare denies payment.

    Please review the attached ABN and complete the form as follows:

     

  • IF YOU ELECT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED

    • Check “OPTION 1” on the attached form; 
    • Sign and date the attached form;
    • The practice will submit the claim for the listed services to Medicare. Note that you may be billed while Medicare is making its decision; 
    • If Medicare pays the claim, you will be refunded any payments that are due to you;
    • If Medicare denies the claim, you will be personally responsible for full payment of the services rendered;
    • You will have the right to appeal Medicare’s decision.
  • IF YOU ELECT NOT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED

    • You must check “OPTION 2” on the attached form;

    • Sign and date the attached form;

    • The practice will not submit the claim to Medicare.


    ALTHOUGH MEDICARE MAY NOT COVER THE LISTED ITEMS OR SERVICES, THERE MAY BE A GOOD REASON FOR YOUR PHYSICIAN RECOMMENDING THE LISTED COURSE OF CARE. PLEASE NOTIFY YOUR DOCTOR OF ANY REFUSAL OF CARE.

  • NOTE: If Medicare doesn’t pay for your (D. service), you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. 

  • WHAT YOU NEED TO DO NOW:

    • Read this notice, so you can make an informed decision about your care.
    • Ask us any questions that you may have after you finish reading.
    • Choose an option below about whether to receive  D (service listed above) .

    Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

     

  • Additional Information:

    This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

    Signing below means that you have received and understand this notice.

     

  • Clear
  • CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

  • According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

  •  
  • Should be Empty: