Advance Beneficiary Notice of Non-coverage (ABN) - LCOHPA

Peter White LPCC

Advance Beneficiary Notice of Non-coverage (ABN) (Peter White LPCC) - LCOHPA

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A. Notifier: Lindner Center of HOPE Professional Associates

B. Patient Name:*

First Last

Patient DOB:*

C. Identification Number:

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for D. Outpatient 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. Outpatient below.

D.	E. Reason Medicare May Not Pay:	F. Estimated Cost:
Medicare A & B: Outpatient Therapy & Medication	Peter White, LPCC is not a Medicare provider, therefore Medicare will not pay for his services.	$60-$240 per visit
Medicare Part D: Pharmacy	Medicare will also not pay for prescriptions written by Non-Medicareproviders.
Enter Applicable YTD Range/Duration:

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. Outpatient 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. I want the D. Outpatient 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 aMedicare 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 the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the D. Outpatient listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3. I don’t want the D. Outpatient 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). 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: [email protected].

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