A. Notifier: 8. 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. ee ene ee 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. 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. '¥ OPTION 1. | want the D. listed above. You may ask to be paid now, but | also want Medicare billed for an official decision on payment, which is sent to me on aMedicare Summary Notice (MSN). | understand that if Medicare doesn’t pay, | am responsible for payment, but | can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments | made to you, less co-pays ordeductibles. 0 OPTION 2. | wantthe D. listed above, but do not bill Medicare. You | ask to be paid now as | am responsible for payment. | cannot appeal if Medicare is notbilled. C OPTION 3. | don't want the D. listed above. | understand with this choice | am not responsible for payment, and | 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 on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that youve received and understand this notice, You also receive a copy. J. Date: CMS does not discrimi: nate-in its programs and activities. To request this blica alternative fornia call: 1-800- MEDICARE or email: in According t0 the Paperwork Reduction Act of 1995, no persans are required to Fespand to a collection of information unless it displays a valid OMB control member The vatid OMB control number for this informanon collection ts 0938-0566. The time Tequired to compicte this information collection is estimated to average 7 memates pet response, icluding the time to review instructions, search existing data resources, eather the data needed, and complete and review the information callection If you have comments conceming the accurcy of the time estimate or suggestions foe linprowung thes form please write to: CMS, 7500 Secunty Boulevard, Arn PRA Reports Clearance Officer, Baltimore, Maryland 21244-1450 Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566 EFTA00313942