Advance Beneficiary Notice Form - Track Change version

Patient name:
Identification number: (optional)

Notifier name
Notifier address
Notifier phone (including TTY)

A.
B.

Patient Name:

Notifier:

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C. Identification Number:

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Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn’t pay for D.

below, you may have to pay.

Medicare does n’ot 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. item, test,
service or care listed below. If Medicare doesn’t pay, you may have to pay.

D.Item, test, service or care

E. Reason Medicare mMay nNot
pPay:

...

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F. Estimated
cCost

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WHAT YOU NEED TO DO NOW:What to do now

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Read this notice , so you canto make an informed decision about your care.
Ask us any questions that you have after you finish reading.
Choose one option below to let us know if you still want to receive the D. get the item, test,
service or care.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.

•
•

•

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G. OPTIONS:
Check only one boxChoose ONE option below. We can’not choose a
box for you.
If you choose Option 1 or 2, we may help you use any other insurance you might have, but
Medicare can’t require us to do this.

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Option 1: OPTION 1. I want the item, test, service or care D. listed above, and I want
Medicare to be billed for an official decision on payment, which I’ll get on a Medicare
Summary Notice (MSN).. You may can 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 to 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 minus co-pays or deductibles.
□ Option 2:

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0B

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o

OPTION 2. I want the item, test, service or care listed aboveD.
listed above, but
do n’ot bill Medicare. You may can ask to be paid now as and I’ am responsible for to
payment. I understand that I can’not appeal, since if Medicare is n’ot billed.
□ Option 3:
Form CMS-R-131 (Exp. XX/XX/XXXX01/31/2026)

Form Approved OMB No. 0938-0566

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OPTION 3. I don’t want the item, test, service or care D.
listed above. I understand
with this choice I’ am not responsible for payment, and I can’not appeal to see if Medicare
would pay.

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H.

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I. Additional information::

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This notice gives our opinion, not an official Medicare decision. For other questions about this
notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227). /TTY users can call : 1-877486-2048. Signing below means that you have received and understand this notice. You may can
ask to receive get a copy.

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I. Signature:

J. Date (mm/dd/yyyy):

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You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You
also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination-notice.

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PRA Disclosure Statement

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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. This information collection is for providers, suppliers, Hospice and
Religious Non-medical HealthCare Institutes and Home Health Agencies to notify original Medicare
beneficiaries of their potential financial liability under specific conditions. The time required to complete
this information collection is estimated to average less than X minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and complete the
information collection. This information collection is mandatory under Section 1879 of the Social Security
Act, 42 CFR 411.404(b) and (c) and 411.408(d)(2) and (f). If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

Paperwork Reduction Act: 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.

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Form CMS-R-131 (Exp. XX/XX/XXXX01/31/2026)

Form Approved OMB No. 0938-0566