NOMNC

NOTICE OF MEDICARE NON-COVERAGE
This Page To Be Completed By All Care Admitting Staff
I agree, as an All Care Employee, that I will follow the policy set forth by All Care Health Solutions regarding Electronic Signatures and will have the Patient or Patient Representative sign and initial all required signature/initial fields*

Yes
I agree, as an All Care Employee, that I will provide a paper copy of the complete NOMNC form to the Patient or Patient Representative at the time of completing this form. I will also go through the Notice of Medicare Non Coverage with the Patient/Representative while completing this form.*

Yes
All Care Staff Full Name*
All Care Staff Email Address*
ALL CARE STAFF SIGNATURE*

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NOTE: FOR BEST SIGNATURE RESULTS, DO NOT ROTATE PHONE

NOTICE OF MEDICARE NON-COVERAGE (NOMNC)
Patient Full Name (LAST, FIRST)*
Patient Medical Record Number - (MRxxxxx)*
Please gather Medical Record Number from Patient Chart. Example MR12345
The Effective Date Coverage of Your Current Home Health Services Will End:
Date Services Will End*

MonthDayYear
DATE OF LAST VISIT
Signature Date*

MonthDayYear
MINIMUM 48 HOURS PRIOR TO DATE SERVICES WILL END, OR UP TO 2 VISITS PRIOR

APPEALS AND MORE INFO, CLICK HERE....
- Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after theeffective date indicated above.
- You may have to pay for any services you receive after the above date.
Your Right to Appeal This Decision
- You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continueduring the appeal.
- If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will look at your medical records and/or other relevant information.You do not have to prepare anything in writing, but you have the right to do so ifyou wish.
- If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should notcontinue. You will receive this detailed notice only after you request an appeal.
- If you choose to appeal, and the independent reviewer agrees services should no longer be covered after the effective date indicated above;
  Neither Medicare nor your plan will pay for these services after that date.
- If you stop services no later than the effective date indicated above, you will avoid financial liability.
How to Ask For an Immediate Appeal
- You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services.
- Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.
- The QIO will notify you of its decision as soon as possible, generally no later than two days after the effective date of this notice if you are in Original Medicare. If you are in a Medicare health plan, the QIO generally will notify you of its decision by the effective date of this notice.
- Call your QIO at: Comagine Health 1-800-488-1118 to appeal, or if you have questions.
- See page 2 of this notice for more information.
Form CMS 10123-NOMNC (Approved 12/31/2011)
If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights:

•If you have Original Medicare: Call the QIO listed on page 1.
•If you belong to a Medicare health plan: Call your plan at the number given below.

Please sign below to indicate you received and understood this notice.

I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.

SIGNATURE FIELD TO BE COMPLETED BY PATIENT ONLY!
ELECTRONIC SIGNATURE CONSENT*

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting "I agree" using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Signature of Patient or Representative*

Clear
FOR BEST SIGNATURE RESULTS, DO NOT ROTATE PHONE
Form CMS 10123-NOMNC (Approved 12/31/2011)
(OPTIONAL) PATIENT EMAIL ADDRESS
If patient would like a copy of the signed NOMNC form emailed to them
Should be Empty:

NOTICE OF MEDICARE NON-COVERAGE

This Page To Be Completed By All Care Admitting Staff

NOTICE OF MEDICARE NON-COVERAGE (NOMNC)

SIGNATURE FIELD TO BE COMPLETED BY PATIENT ONLY!