Advance Beneficiary Notice of Non-coverage (ABN)

Riverbend Family Clinic 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY: 711) Patient name: Dorothy Hale ## Advance Beneficiary Notice (ABN): Medicare May Not Pay Medicare does not pay for every test or service. This means you may have to pay for some care yourself. We think Medicare may not pay for the test listed below. If Medicare does not pay, you may have to pay the bill. - **Test:** Vitamin D blood test - **Why Medicare may not pay:** Medicare usually pays for this test only one time every 12 months. - **Estimated cost:** $187.50 ## What you need to do - Read this notice so you can decide what you want to do. - Ask us any questions you have. - Pick one of the options below to tell us what you want. You must pick ONE option. We cannot pick for you. If you pick Option 1 or Option 2, we may help you use any other insurance you have. Medicare cannot make us do this. - **Option 1:** I want the test. I want Medicare to be billed so that Medicare makes an official decision about whether it will pay. I will get the decision in a letter called a Medicare Summary Notice (MSN). I can ask to pay now. I understand that if Medicare does not pay, I have to pay. I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, the clinic will give back any money I paid, minus any co-pays or deductibles. - **Option 2:** I want the test, but do not bill Medicare. I can ask to pay now, and I will have to pay the bill. I understand that I cannot appeal, because Medicare was not billed. - **Option 3:** I do not want the test. I understand that I do not have to pay for it, and I cannot appeal to see if Medicare would have paid. ## More information This notice is the clinic's opinion. It is not an official Medicare decision. If you have other questions about this notice or about Medicare billing, call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048. Signing below means you got this notice and understand it. You can ask for a copy. Signature: ____________ Date (mm/dd/yyyy): ____________ You have the right to get Medicare information in a format you can use, such as large print, Braille, or audio. You also have the right to file a complaint if you feel you were treated unfairly because of who you are. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice for more information.

**Riverbend Family Clinic** 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY: 711) **Patient name:** Dorothy Hale ## Notice: Medicare May Not Pay for Your Care Medicare does not pay for everything. Sometimes it does not pay for care that you or your doctor think you need. If Medicare does not pay, you may have to pay. **We think Medicare may not pay for this:** - **What it is:** Vitamin D blood test - **Why Medicare may not pay:** Medicare usually pays for this test only one time every 12 months. - **What it may cost you:** $187.50 ## What you need to do 1. Read this notice. It will help you decide what you want to do. 2. Ask us any questions you have. 3. Pick **one** option below. Tell us if you still want the test. We can't pick for you. If you pick Option 1 or Option 2, we may help you use other insurance you have. But Medicare cannot make us do this. **Option 1: Yes, I want the test, and please bill Medicare.** - Medicare will look at the bill and decide if it will pay. You will get a letter from Medicare with its decision. It is called a Medicare Summary Notice (MSN). - We may ask you to pay now. - If Medicare says no, I must pay. But I can appeal. That means I can ask Medicare to look at the decision again. The MSN will tell me how. - If Medicare says yes, the clinic will give back what I paid. I will still owe any co-pay or deductible. **Option 2: Yes, I want the test, but do not bill Medicare.** - We may ask you to pay now. - I must pay for the test. - I cannot appeal. That is because Medicare will not see the bill. **Option 3: No, I do not want the test.** - I will not have to pay. - I cannot appeal. That is because Medicare will not be asked if it would pay. ## More information - This notice is only our opinion. It is not Medicare's final decision. - Do you have questions about this notice or Medicare bills? Call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048. - When you sign below, it means you got this notice and understand it. You can ask for a copy. **Signature:** ____________ **Date (mm/dd/yyyy):** ____________ ## Your rights - You can get Medicare information in a format that is easy for you to use. This includes large print, Braille, or audio. - You can make a complaint if you think you were treated unfairly. Go to: Medicare.gov/about-us/accessibility-nondiscrimination-notice

Riverbend Family Clinic 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY: 711) Patient name: Dorothy Hale ## Medicare May Not Pay for This Test Medicare does not pay for everything. It may not pay for some care, even if you or your doctor think you need it. We think Medicare may not pay for the test below. If Medicare does not pay, you may have to pay for it yourself. - **Test:** Vitamin D blood test - **Why Medicare may not pay:** Medicare usually pays for this test only once every 12 months. - **About how much it costs:** $187.50 ## What to Do Now 1. Read this letter so you can decide what is best for you. 2. Ask us any questions you have. 3. Pick one choice below. This tells us if you still want the test. **You must pick only ONE choice. We can't pick for you.** If you pick Choice 1 or Choice 2, we may help you use any other health insurance you have. But Medicare does not make us do this. **☐ Choice 1: Yes, I want the test. Send the bill to Medicare.** - Medicare will decide if it will pay. - You will get a letter from Medicare called a Medicare Summary Notice (MSN). It will tell you what Medicare decided. - We may ask you to pay now. - If Medicare does not pay, you will have to pay. - If you don't agree with Medicare's decision, you can ask Medicare to look at it again. This is called an appeal. The MSN will tell you how to do this. - If Medicare does pay, we will give back the money you paid us. We will keep only your co-pay or deductible (the part you always have to pay yourself). **☐ Choice 2: Yes, I want the test. Do NOT send the bill to Medicare.** - We may ask you to pay now. - You will have to pay. - You can't ask Medicare to look at it again (no appeal), because Medicare will not get the bill. **☐ Choice 3: No, I do NOT want the test.** - You will not have to pay. - You can't ask Medicare to look at it again to see if it would have paid. ## More Information This letter tells you what we think. It is not Medicare's final decision. If you have questions about this letter or about Medicare bills, call Medicare at 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048. When you sign below, it means you got this letter and you understand it. You can ask us for a copy. Signature: ____________ Date (mm/dd/yyyy): ____________ You have the right to get Medicare information in a way that works for you, like large print, Braille, or audio. If you feel you were treated unfairly, you have the right to complain. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.

**Riverbend Family Clinic** 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY 711) **Patient: Dorothy Hale** ## Notice: Medicare May Not Pay for Your Test Medicare does not pay for everything. Sometimes it won't pay for care that you or your doctor think you need. If Medicare does not pay, you may have to pay. **We think Medicare may not pay for this:** - **Test:** Vitamin D blood test - **Why:** Medicare usually pays for this test only one time every 12 months. - **Cost:** About $187.50 ## What you need to do 1. Read this letter. 2. Ask us any questions you have. 3. Pick **one** choice below. We cannot pick for you. If you pick Choice 1 or Choice 2, we may help you use other insurance, if you have any. But Medicare cannot make us do this. **Choice 1: Yes, I want the test. Send the bill to Medicare.** - Medicare will look at the bill and decide if it will pay. - You will get a letter from Medicare called a Medicare Summary Notice (MSN). - We may ask you to pay now. - If Medicare says no, you must pay. You can appeal. This means you can ask Medicare to look again. The MSN will tell you how. - If Medicare says yes, we will give back what you paid. You may still owe a co-pay or deductible. **Choice 2: Yes, I want the test. Do not send the bill to Medicare.** - We may ask you to pay now. - You must pay the bill. - You cannot appeal. Medicare is not being asked to pay, so it cannot make a decision. **Choice 3: No, I do not want the test.** - You do not have to pay. - You cannot appeal. Medicare will not get to decide if it would have paid. ## More to know - This letter is only our opinion. It is not Medicare's final decision. - Have questions about this letter or Medicare bills? Call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048. - When you sign below, it means you got this letter and understand it. You can ask for a copy. **Your signature:** ____________ **Date (month/day/year):** ____________ ## Your rights - You can get Medicare information in large print, Braille, or audio. - You can make a complaint if you feel you were treated unfairly because of who you are. - To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice.

**Riverbend Family Clinic** 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY: 711) **Patient name:** Dorothy Hale ## Notice: Medicare May Not Pay for Your Care Medicare does not pay for everything. This is true even for care that you or your doctor think you need. We think Medicare may not pay for the test below. If Medicare says no, you may have to pay the bill yourself. **Test:** Vitamin D blood test **Why Medicare may not pay:** Medicare usually pays for this test only one time every 12 months. **Estimated cost:** $187.50 ## What you need to do 1. Read this notice carefully so you can make a good choice. 2. Ask us any questions you have. 3. Pick one of the three options below. Tell us if you still want the test. We can't pick for you. If you pick Option 1 or Option 2, we may be able to help you bill any other insurance you have. But Medicare can't make us do this. ### Your options **Option 1: I want the test, and I want Medicare to be billed.** - Medicare will make an official decision about payment. You will get this decision in a letter called a Medicare Summary Notice (MSN). - We can ask you to pay now. - If Medicare says no, you must pay the bill. But you can appeal (ask Medicare to look at the decision again). The MSN will tell you how. - If Medicare says yes, we will give back any money you paid us. We will keep only your co-pays or deductibles. **Option 2: I want the test, but do not bill Medicare.** - We can ask you to pay now. - You must pay the bill. - You cannot appeal, because Medicare will not be billed. **Option 3: I do not want the test.** - You do not have to pay anything. - You cannot appeal. That means you will not find out if Medicare would have paid. ## More information - This notice is our opinion. It is not an official Medicare decision. - If you have questions about this notice or Medicare bills, call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048. - When you sign below, it means you got this notice and understand it. You can ask for a copy. **Signature:** ______________________ **Date (mm/dd/yyyy):** ______________ ## Your rights - You can get Medicare information in a way that works for you, such as large print, Braille, or audio. - You can file a complaint if you think you were treated unfairly because of who you are. - To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.

**Riverbend Family Clinic** 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY: 711) **Patient name:** Dorothy Hale # Notice: Medicare May Not Pay for Your Care Medicare does not pay for everything. This is true even for some care that you or your doctor think you need. We think Medicare may not pay for the care listed below. If Medicare does not pay, you may have to pay. **What the care is:** A vitamin D blood test **Why Medicare may not pay:** Medicare usually pays for this test only one time every 12 months. **What it may cost:** $187.50 ## What you need to do now 1. Read this notice. It will help you make a good choice about your care. 2. Ask us any questions you have. 3. Pick one of the three choices below. This tells us if you still want the test. We can't pick for you. If you pick Option 1 or Option 2, we may help you use any other insurance you have. But Medicare cannot make us do this. ## Your choices **Option 1: Yes, I want the test, and bill Medicare.** - I want the vitamin D blood test. - Medicare will be billed. Medicare will then make an official decision about payment. I will get the decision in a letter called a Medicare Summary Notice (MSN). - You can ask me to pay now. - If Medicare does not pay, I must pay. - If Medicare does not pay, I can appeal. An appeal means asking Medicare to look at the decision again. The MSN will tell me how to do this. - If Medicare does pay, you will give back any money I paid you. You will keep my co-pays and deductibles. (A co-pay is a set amount I pay for a service. A deductible is the amount I pay before Medicare starts to pay.) **Option 2: Yes, I want the test, but do not bill Medicare.** - I want the vitamin D blood test. - Do not bill Medicare. - You can ask me to pay now. - I must pay. - I cannot appeal. This is because Medicare is not billed. **Option 3: No, I do not want the test.** - I do not want the vitamin D blood test. - I do not have to pay anything. - I cannot appeal to find out if Medicare would have paid. ## More information - This notice is only our opinion. It is not an official Medicare decision. - If you have other questions about this notice or Medicare bills, call Medicare at **1-800-MEDICARE (1-800-633-4227)**. - If you use a TTY, call **1-877-486-2048**. - You can also call our clinic at **931-555-0147** (TTY: 711). - When you sign below, it means you got this notice and understand it. - You can ask for a copy of this notice. **Signature:** ____________________ **Date (month/day/year):** ____________________ ## Your rights - You have the right to get Medicare information in a form that works for you. This includes large print, Braille, or audio. - You have the right to file a complaint if you think you were treated unfairly because of who you are. - To learn more, go to: Medicare.gov/about-us/accessibility-nondiscrimination-notice

**Riverbend Family Clinic** 410 Main Street, Columbia, TN 38401 Phone: 931-555-0147 (TTY 711) **Patient name:** Dorothy Hale # Medicare May Not Pay for Your Test This is an Advance Beneficiary Notice of Non-coverage (ABN). Medicare does not pay for everything. This is true even for some care that you or your health care provider think you need. We think Medicare may not pay for the test listed below. If Medicare does not pay, you may have to pay. - **Test:** Vitamin D blood test - **Why Medicare may not pay:** Medicare usually pays for this test only once every 12 months. - **Estimated cost:** $187.50 # What to Do Now 1. Read this notice. It will help you make an informed choice about your care. 2. Ask us any questions you have. 3. Choose one option below. Tell us if you still want the test. **Choose only ONE option. We can't choose for you.** If you choose Option 1 or Option 2, we may help you use any other insurance you have. But Medicare can't make us do this. ## Option 1: Get the test, and Medicare is billed - I want the vitamin D blood test. - I want Medicare to be billed. Medicare will make an official decision about payment. I will get that decision on a Medicare Summary Notice (MSN). - You can ask me to pay now. - If Medicare does not pay, I am responsible for paying. - I can appeal to Medicare. I do this by following the directions on the MSN. - If Medicare does pay, you will give back any money I paid you. You will keep only my co-pays or deductibles. ## Option 2: Get the test, and Medicare is not billed - I want the vitamin D blood test. - Do not bill Medicare. - You can ask me to pay now. - I am responsible for paying. - I can't appeal, because Medicare is not billed. ## Option 3: Do not get the test - I do not want the vitamin D blood test. - I am not responsible for paying. - I can't appeal to find out if Medicare would pay. # More Information - This notice is our opinion. It is not an official Medicare decision. - Do you have other questions about this notice or Medicare billing? Call **1-800-MEDICARE (1-800-633-4227)**. - TTY users can call **1-877-486-2048**. - When you sign below, it means you got this notice and understand it. - You can ask for a copy of this notice. **Signature:** ____________________ **Date (mm/dd/yyyy):** ____________________ # Your Rights - You have the right to get Medicare information in a way that works for you. This can be large print, Braille, or audio. - You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination). - To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.