Advance Beneficiary Notice of Non-Coverage (ABN)

A. Notifier:

B. Patient Name:

C. Identification Number:

NOTE: If Medicare doesn't pay for D. below, 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 D. below

E. Reason Medicare May Not Pay:

F. Estimate Cost:

G. OPTIONS. Check only one box. We cannot choose a box for you.

What You Need To Know

Option 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare 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 refund any payments I made to you, less co-pays or deductibles.

Option 2. I want the D. 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 D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

Read this notice, so you can make an informed decision about your care.

1. Ask us any questions that may have after you finish reading.
2. Choose an option below about whether to receive the D. 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.

H. Additional Information:

This notice gives your 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. You also receive a copy.

I. Signature

J. Date

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Advance Beneficiary Notice of Non-Coverage (ABN)

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