Therapeutic Phlebotomy Advance Beneficiary Notice of Non-coverage (ABN)

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A. Notifier: Institute of Complementary Medicine

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B. Patient Name* This field is required.

First Name

Last Name

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Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Insurance doesn’t pay for D. below, you may have to pay. Insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Insurance may not pay for the D.

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D.

E. Reason Insurance May Not Pay:

F. Estimated Cost

Therapeutic Phelebotomy

CP 99195

Non-covered service

$100

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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 the D. listed above.

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G. Options: Check only one box. We cannot choose a box for you.* This field is required.

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H. Addition Information:

This notice gives our opinion, not an official insurance decision. If you have other questions on this notice or insurance billing, call the number listed on your insurance card. Signing below means that you have received and understand this notice. You also will receive a copy.

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I. Signature* This field is required.

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J. Date:* This field is required.

Date