Usmd Advance Beneficiary Notice Of Noncoverage printable pdf download

ADVANCE BENEFICIARY

NOTICE OF NONCOVERAGE

Patient:

____________________________________________

Identiﬁcation Number:

_________________________________

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn’t pay for Item(s) and Service(s) 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 Item(s) and Service(s) below.

Item(s) or Service(s)

Reason Medicare May Not Pay:

Estimated Cost:

________ Medicare does not pay for these tests for your condition

________ Medicare does not pay for these tests this often

________ Medicare does not pay for research use tests

________ Other: ___________________________________________

What you need to do now:

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

Ask us any question that you may have after you ﬁnish reading.

Choose an option below about whether to receive the Item(s) and Service(s) listed above.

Options:

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

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.

Option 1

I want the Item(s) and Service(s) 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 Item(s) and Service(s) 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 Item(s) and Service(s) listed above.

I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

Form CMS-R-131 (03/08)

Form Approved OMB No. 0938-0566

Usmd Advance Beneficiary Notice Of Noncoverage