Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for Medical Nutrition Therapy, 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 Medical Nutrition Therapy if you do not have diabetes or renal disease. Estimated costs per session: $160.00/hour for initial sessions, $120.00/hour for follow up sessions.

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 Medical Nutrition Therapy.

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.

Options

Check only one box. We cannot make this selection for you.

OPTION 1. I want Medical Nutrition Therapy. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want Medical Nutrition Therapy, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3. I don’t want Medical Nutrition Therapy. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

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.

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Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566