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Advance Beneficiary Notice of Noncoverage (ABN)
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A.Notifier: Synergy Chiropractic & Health Center
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B.Patient Name:
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C. Identification Number
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NOTE: If Medicare doesn't pay for D. below, you may have to pay.
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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. below.
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D. SERVICE OR PROCEDURE
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E. Reason Medicare May Not Pay: Not within Guidelines
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F. Estimated Cost:
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• New/Existing Patient Re-Exam Massage Therapy: • $150/$55
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• Prep massage (10-15 minutes) • $25
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• 30 minute massage • $50
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• 60 minute massage • $90
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• Summus Laser • $75
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• PRP. • $75
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• Aline Orthotics. • $75 + $90= $165
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• WHARTONS JELLY . • $1100 PER ML
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WHAT YOU NEED TO DO NOW:
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• Read this notice, so you can make an informed decision about your care.
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• Ask us any questions that you may have after you finish reading.
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• Choose an option below about whether to receive the D. 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.
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G. OPTIONS: Check only one box. We cannot choose a box for you.
• • •
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H. Additional Information:
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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).
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Signing below means that you have received and understand this notice. You also receive a copy.
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I. Signature:
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J. Date:
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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.
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The time required to complete this information collection is estimated to average 7 minutes per response.
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Including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
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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.
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Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566
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