NOTE: If Medicare doesn't pay for the Services To Be Provided below, you may have to pay.
Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We accept Medicare may not pay for the Office Visit below.
E. REASON MEDICARE MAY NOT PAY:
Not indicated for diagnosis and/or treatment in this case
F. ESTIMATED COST:
No More than $600
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. Services To Be Provided 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.
G. OPTIONS: Check only one box. We cannot choose a box for you.
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).
CMS does not discriminate in its program and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
According to the Paperwork 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 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.
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