Forms

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 everthing, 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.

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.

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 you have received and understand this notice. You also receive a copy.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

Accoridng to the paperwork reduction Act of Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form. please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 03/2020)
Form Approved OMB No. 0938-0566

Routine Foot Care General Information

Routine foot care is not a covered medicare benefit. Medicare assumes that the patient or caregiver will perfume these services by themselves, and therefore, these services are excluded from coverage with certain exceptions. The Center for Medicare and Medicaid Services (CMS) has established national-level guidelines governing routine foot care and treatment of mycotic nails.

Routine foot care is defines as:

• The cutting or removal of corns or calluses
• The trimming, cutting, clipping or debriding of nails.
• Hygienic and preventative maintenance care such as:

1. Cleaning and soaking the feet.
2. The use of skin creams to maintain skin tone of either ambulatory or bedfast patients.
3. Any other services perfomed in the absence of localized illness, injury or symptoms involving foot.

Exceptions

Medicare allows exceptions to this exclusion when medical conditions exist that place the beneficiary at increased risk of infection and/or injury if a non-professional would provide these services. Medicare may cover routine foot care if it is a necessary and integral part of otherwise covered services.

In certain circumstances, services ordinarily considered to ve routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds or infections.

Systemic Condition

The presence of a systemic condition such as metabolic, neurologic or peripheral vascular disease may resuly in severe circulatory embarrassment or areas of diminished sensation in the individual's leg or feet. In these instances, certain foot care procedures that otherwise are considered routine (as defined previously) may pose a hazard when performed by a nonprofessional person.

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practice provides information about how we may use of disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not requred to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By Signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writng, signed by you, However, such a revocation will be retroactive.

By signing this form, I understand that:

• Protected health infromation may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions
• The patient has the irght to revoke this consent in writing at any time and all full disclosures wil then cease.
• The practice may condition receipt of treatment upon execution of this consent.

If Yes, Please name the member allowed

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.