ABN English

notifier health first chiropractic & rehabilitation advance beneficiary notice of noncoverage (abn) note if medicare doesn’t pay for d therapies 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 therapies below d e reason medicare may not pay f estimated cost electrical stimulation therapeutic exercise ultrasound spinal decompression not medically necessary $20 00 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 g options check only one box we cannot choose a box for you option 1 option 2 option 3 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 i signature j date 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 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 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