Advance Beneficiary Notice Of Noncoverage (Abn) printable pdf download

Personalized Primary Care,

EFFECTIVE 11/1/11

A. Notifier: James G. Scelfo, MD, PA DBA/// Personalized Primary Care

B. Patient Name:

C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE:

If Aetna doesn’t pay for D. The Annually/Monthly Membership fee to James G. Scelfo, MD, PA DBA/// Personalized Primary Care or the

amenities liston the first page of the PPC Membership Agreement below, you may have to pay. Aetna does not pay for everything, even some care

that you or your health care provider have

good reason to think you need. We expect Aetna may not pay for the D The Annually/Monthly Membership fee to James G. Scelfo, MD, PA

DBA/// Personalized Primary Care or the amenities liston the first page of the PPC Membership Agreement below.

E. Reason Aetna May

F. Estimated Cost

Not Pay:

The Annually/Monthly Membership

Is a non covered service not

Membership fees Include:

fee to James G. Scelfo, MD, PA

paid by any insurane

DBA/// Personalized Primary Care or

company.

Invididual

$1800

the amenities liston the first page of the

Couple

$3100

PPC Membership Agreement

Child up to -18yrs $500

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.

Note: If you choose Option 1 or 2, we may help you to use any other insurance

that you might have, but Aetna cannot require us to do this.

G. O

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

PTIONS

☐ OPTION 1. I want the D.

listed above. You may ask to be paid now, but I

also want Aetna billed for an official decision on payment, which is sent to me on a Aetna

Summary Notice (MSN). I understand that if Aetna doesn’t pay, I am responsible for payment,

but I can appeal Aetna by following the directions on the MSN. If Aetna 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 Aetna. You may ask

to be paid now as I am responsible for payment. I cannot appeal if Aetna 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 Aetna would pay.

H. Additional Information:

This notice gives our opinion, not an official Aetna decision. If you have other questions on

this notice or Aetna billing, Please call.

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

I. Signature:

J. 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 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.

Form CMS-R-131 (03/11)

Form Approved OMB No. 0938-0566