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Free Advance Beneficiary Notice of Non-coverage Form in PDF

The Advance Beneficiary Notice of Non-coverage (ABN) is a crucial document used by healthcare providers to inform Medicare beneficiaries that a service or item may not be covered by Medicare. This notice allows patients to make informed decisions about their care and potential out-of-pocket costs. Understanding the ABN is essential for navigating the complexities of Medicare coverage.

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Document Sample

	Name of Practice
	Letterhead
A. Notifier:
B. Patient Name:	C. Identification Number:

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If your insurance doesn’t pay for D.below, you may have to pay.

Your insurance (name of insurance co) may not offer coverage for the following services even though your health care provider advises these services are medically necessary and justified for your diagnoses.

We expect (name of insurance co) may not pay for the D.		below.

E. Reason Insurnace May Not Pay:

F.Estimated Cost

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.as above.

Note: If you choose Option 1 or 2, we may help you to appeal to your insurance company for coverage

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

	my insurance billed for an official decision on payment, which is sent to me as an Explanation of
	Benefits. I understand that if my insurance doesn’t pay, I am responsible for payment, but I can appeal
	to __(insurance co name)____. If _(insurance co name_ 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 (insurance co name). You

	may ask to be paid now as I am responsible for payment
	☐ OPTION 3. I don’t want the D.			listed above. I understand with this choice I am not

	responsible for payment.
H. Additional Information:

This notice gives our opinion, not a denial from your insurance company. If you have other questions on this notice please ask the front desk person, the billing person, or the physician before you sign below.

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

	I. Signature:	J. Date:

October 2016 revision

Download Advance Beneficiary Notice of Non-coverage PDF

Key takeaways

The Advance Beneficiary Notice of Non-coverage (ABN) form is an important document that helps beneficiaries understand their rights regarding Medicare coverage. Here are some key takeaways about filling out and using this form:

Understand the Purpose: The ABN informs beneficiaries that a service or item may not be covered by Medicare. It allows individuals to make informed decisions about their healthcare options.
Fill It Out Carefully: When completing the ABN, ensure that all required fields are filled out accurately. This includes the patient's name, the date, and the specific service being provided.
Provide Clear Explanations: The form should include a clear explanation of why the service may not be covered. This helps beneficiaries understand their potential financial responsibility.
Keep a Copy: Both the provider and the beneficiary should retain a copy of the signed ABN. This serves as proof that the beneficiary was informed about the non-coverage prior to receiving the service.
Use It Wisely: The ABN is not required for every service. Use it only when there is a reasonable expectation that Medicare may deny coverage, ensuring that the process remains efficient and transparent.

By following these guidelines, beneficiaries can navigate the complexities of Medicare coverage more effectively.

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Instructions on How to Fill Out Advance Beneficiary Notice of Non-coverage

When you receive a service that Medicare may not cover, it’s important to communicate this clearly. The Advance Beneficiary Notice of Non-coverage (ABN) form is a tool that helps you understand your potential financial responsibility for services rendered. Completing this form accurately ensures that you are informed about your options and any possible costs involved.

Begin by entering the date on which you are filling out the form at the top of the page.
Provide your name and address in the designated sections. This helps identify you as the patient.
Fill in your Medicare number, which can usually be found on your Medicare card.
In the next section, clearly describe the service or item that you are receiving. Be specific to avoid confusion.
Indicate the reason why you believe Medicare may not cover the service. This could be due to various factors, such as the service being deemed not medically necessary.
Review the statement that explains your financial responsibility. Make sure you understand the implications of signing the form.
Sign and date the form at the bottom to acknowledge that you have received this notice and understand the information provided.

Once you have completed the form, keep a copy for your records. It’s advisable to discuss any questions you may have with your healthcare provider to ensure clarity regarding your coverage and any associated costs.