Advance Beneficiary Notice of Non-coverage (ABN) (Paul Keck MD) - LCOHPA

  • A. Notifier: Lindner Center of HOPE Professional Associates

  • Date Format: MM slash DD slash YYYY

  • Advance Beneficiary Notice of Non-coverage (ABN) (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 Management Paul Keck, MD is not a Medicare provider, therefore Medicare will not pay for his services. $60-$385 per visit
    Medicare Part D: Pharmacy Medicare will also not pay for prescriptions written by Non-Medicare providers.
    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.

  • Date Format: MM slash DD slash YYYY
  • 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.

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