Advanced Beneficiary Notice

Patient Name:

As you know, Medicare does not pay for everything, even some services that you or your physician consider medically necessary. Medicare does not pay for the services listed below because they are not Medicare-covered benefits, which means you are responsible for payment at the time of service. You will be charged only for services actually provided to you, and only upon your request or the request of a person responsible for your care.

Trip Fee – Waived in senior communities on scheduled visit days

Weekdays $95
Weekends $120
Out-of-Area Surcharge

Telephone consultations not “bundled” into an encounter

$55/quarter hour

Administrative services by office staff, upon patient/family request

$15/quarter hour

Foot Care (non-qualified patients only)

Option 1

I want the services listed above when applicable to my care, except those I did not check. I will pay for them at the time of service, but I also want you to bill Medicare for an official decision on payment, which I can appeal if payment is denied. If Medicare does pay, you will refund any payment I made, less co-pays or deductibles.

Option 2

I want the services listed above when applicable to my care, except those I did not check, and agree to pay for them because I understand that those services are not covered by Medicare or supplemental insurance.

Option 3

I don’t want the services listed above. I will not be billed and I cannot appeal to see if Medicare would pay.

Date (DD/MM/YYYY):

By clicking submit, I verify that I am the patient or the patient’s legal representative for the matters covered by this form, and I accept the terms of each provision I’ve checked.

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