When filling out and giving your patients an ABN to sign for services you believe may be denied by Medicare, please be sure the ABN is filled out correctly. If it is not filled out correctly, it will cause the ABN to be void and invalid. Here are special instructions which must be followed to consider the form valid with Medicare:
Blank (A) Notifier(s): Notifiers must place their name, address, and telephone number at the top of the notice.
Blank (B) Patient Name: Notifiers must enter the first and last name of the beneficiary receiving the notice, and a middle initial should also be used if there is one on the beneficiary’s Medicare card.
Blank (C) Identification Number: Use of this field is optional.
Blank (D): The notifier must list the specific items or services believed to be noncovered .
Blank (E) Reason Medicare May Not Pay: Notifiers must explain, in beneficiary friendly language, why they believe the items or services described in Blank (D) may not be covered by Medicare.
Blank (F) Estimated Cost: Notifiers must complete Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services.
- “Between $xxx-xxx”
- “No more than $xxx”
Blank (G) Options: The beneficiary or his or her representative must choose only one of the three options listed. Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.
- Additional Information
Blank (H) Additional Information: Notifiers may use this space to provide additional clarification that they believe will be of use to beneficiaries.
- Signature Box
Blank (I) Signature: The beneficiary (or representative) must sign the notice.
Blank (J) Date: The beneficiary (or representative) must write the date he or she signed the ABN
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