(B) Patient Name:
(C) Identification Number:
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
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:
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 (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.
(G) OPTIONS: Check only one box. We cannot choose a box for you.
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.
(H) Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions
this notice or Medicare billing, call 1-800-MEDICARE