A. Notifier: Lindner Center of HOPE Professional Associates
Advance Beneficiary Notice of Non-coverage
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.
||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.
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.
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.