Form Cms R 131 PDF Details

Form CMS R 131 requests payment information from healthcare providers and suppliers. The form is used to determine whether or not the provider or supplier is eligible to participate in the Medicare program. By completing and submitting this form, you agree to the terms set by Medicare. Failure to comply with these terms may result in termination of your Medicare participation. Be sure to read through all instructions before filling out this form.

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QuestionAnswer
Form NameForm Cms R 131
Form Length1 pages
Fillable?Yes
Fillable fields8
Avg. time to fill out1 min 55 sec
Other namesmedicare abn form for printable, CMS-R-131, 1995, abn form printable

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TriHealth Laboratories

Customer Service 513-569-6344

Patient Name:

Account or ID Number:

 

 

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If Medicare doesn’t pay for the laboratory test(s) 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 laboratory test(s) below.

Laboratory Test(s) Reason Medicare May Not Pay

Medicare does not pay for this test for your condition.

Medicare does not pay for this test as often as this.

Medicare does not pay for experimental or research use tests.

Other: __________________________________________

Estimated Cost

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 laboratory test(s) 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.

OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the laboratory test(s) listed above. 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 the laboratory test(s) listed above, 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 the laboratory test(s) listed above. 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.

Signature:

Date:

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. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.

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

TriHealth Laboratories 8/11

How to Edit Form Cms R 131 Online for Free

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medicare abn form printable gaps to complete

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