ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

A. Notifier

B.Patient Name*

First NameLast Name

C. Identification Number*

NOTE: If Medicare doesn't pay for D. 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. We expect Medicare may not pay for the items listed below.

D.

F. Estimated Cost

What do you need to know :
-Read this notice, so you can make an informed decision about your case.

-Ask us any questions that you may have after you finish reading.

-Choose an option below about whether to receive the listed services.

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.

G. Options : Select only one box. We cannot choose a box for you.

OPTION 1. I want the listed services above. You may ask to be paid now, but I also want Medicicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will be refunded any payments I made to you, less co-pays or deductibles.OPTION 2. I want the listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don't want the services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. 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: 1-877-488-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature*

Clear

J. Date*

Date

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 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

Form Approved OMB No. 0938-0566

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

E. Reason Medicare May Not Pay