A. Notifier:

A. Notifier: 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. D. E. Reason Medicare 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. 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. G7OPTIONS: Check only one box. We cannot choose a box foryou. III 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 ordeductibles. 0 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 notbilied. Li 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 on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signingbelow means that ve received and understand this notice. You also receive a copy. I. Signature: f. CMS does nontidimriminacia its programs and activities. To nest Ills nblicatlo alternative for please call: 1-800-MEDICARE or email: J. Date: Lfic)0 &ocotillos tote Pap/murk R.:dottier Act of I495. no wool are required to respell to a cello:hot of mictmarien utiles dicplrys I Sid OMB control Dante. rhe %Mid OMB control number ect this infoonsuon collection 09311-0360 11w iime required to co.mcicte thus information onlectica la meneeled m avast ?mass re/ rmente. &minding the time to mom. incomings. wan", existing dud feSOLOCO, gather tar: dm needed, ird complete and woe* the teotmation onlection If nu Mt comments Cereecning the mmtraty of the time euimnleetfuyptttans IOC Itnprcning this form ;these unto to CMS. 7500 Swum& Boulevard. AIM PRA keprets Chtannee Of leer, &Edmore. Maryland :1244- I150 Form CMS-R-131 (Exp. 0312020) Form Approved OMB No. 0938-0566 EFTA00313942