South Bend Medical Foundation Advance Beneficiary Notice Of Noncoverage (Abn) printable pdf download

530 N. Lafayette Blvd.

•

South Bend, IN 46601

(574) 234-4176

•

(800) 544-0925

Notifier(s):

Patient Name:

Identification Number:

(ABN)

DVANCE

ENEFICIARY

OTICE OF

ONCOVERAGE

NOTE: If Medicare doesn’t pay for laboratory test(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 laboratory test(s) below.

Laboratory Test(s)

Reason Medicare May Not Pay:

Estimated Cost:

Thin Prep Pap, Screening

Medicare does not pay for these tests as often

as this (denied as too frequent)

Occult Blood, Screening

Medicare does not pay for these tests for your

PSA, Screening

condition

Other ______________________________

Medicare does not pay for experimental or

______________________________________

research tests

______________________________________

Other _____________________________________

______________________________________

_____________________________________________

HAT 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 laboratory test(s) listed above.

Note: Although not required by the Medicare program, if you choose Option 1 or 2, we

will help you file any other insurance you have.

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

PTIONS

OPTION 1. I want the laboratory test(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 laboratory test(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 laboratory test(s) listed above. I understand with this choice

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

Additional Information: If option 3 was selected, you should notify your doctor who orders

these laboratory test you did not receive them.

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 1-877-486-2048).

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

Signature:

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 (03/08)

Form Approved OMB NO. 0938-0566

13306 (01/10)