Advance Beneficiary Notice Form Of Noncoverage (Abn), Hand & Orthopedic Physical Therapy Associates, P.c. Pack printable pdf download

Hand & Orthopedic Physical Therapy Associates, P.C.

Patient Name:

Date of Birth:

(ABN)

DVANCE

ENEFICIARY

OTICE OF

ONCOVERAGE

If Medicare doesn’t pay for items listed below, you may have to pay.

NOTE:

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 items listed below.

Reason Medicare May Not Pay:

Estimated

Cost:

Out Patient Physical Therapy

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 services/supplies 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.

PTIONS

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

OPTION 1.

I want the services/supplies 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 services/supplies 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 services/supplies 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:

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 (03/11)

Form Approved OMB No. 0938-0566