Advance Beneficiary Notice of Noncoverage

A. Notifier: Alaska Digestive and Liver Disease

B. First Name:

Middle Initial:

Last Name:

C. Identifaction Number:

Advanced 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

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.

Please Select One

OPTION 1 I want the Services To Be Provided 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 MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2 I want the Services To Be Provided listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I can not appeal if Medicare is not billed. OPTION 3 I don't want the Services To Be Provided 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).

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.

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.

Patient's Name:

Date:

Medicare Long Term Authorization

Name

Medicare #

I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by Daryl M. McClendon, M.D., Jeffrey W. Molloy, M.D., Austin T. Nelson, M.D, Martin P. Kaszubowski, M.D., and/or Terri L. Tope, ANP. I authorize any holder of medical or other information about me be released to the Health Care Financing Administration and its agents for any information needed to determine these benefits for related services

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

Signature / Name

Date

(Authorization good for one year from the above date)

Your information will be encrypted.