Form No Cms R 131 G PDF Details

When completing the form No CMS R 131 G, it is important to provide accurate information. The purpose of this form is to document the reasons for a beneficiary's referral to an outside source for medical care. Completing this form correctly can help ensure that the beneficiary receives the appropriate care. Providing false or misleading information on this form may result in incorrect treatment or services. Remember to be honest and complete all sections of this form accurately in order to ensure that the beneficiary receives the best possible care.

You will see information regarding the type of form you need to fill out in the table. It will show you the span of time you will need to complete form no cms r 131 g, exactly what fields you will have to fill in and several other specific details.

Form NameForm No Cms R 131 G
Form Length1 pages
Fillable fields8
Avg. time to fill out1 min 51 sec
Other namesmedicare abn form editable, blank abn form, abn form, medicare abn form for printable

Form Preview Example

Patient’s Name:

Medicare # (HICN):




NOTE: You need to make a choice about receiving these health care items or services.

We expect that Medicare will not pay for the item(s) or service(s) that are described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for –

Items or Services:


The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.

Ask us to explain, if you don’t understand why Medicare probably won’t pay.

Ask us how much these items or services will cost you (Estimated Cost: $_________________),

in case you have to pay for them yourself or through other insurance.


Option 1. YES. I want to receive these items or services.

I understand that Medicare will not decide whether to pay unless I receive these items or services. Please submit my claim to Medicare. I understand that you may bill me for items or services and that I may have to pay the bill while Medicare is making its decision.

If Medicare does pay, you will refund to me any payments I made to you that are due to me. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal Medicare’s decision.

Option 2. NO. I have decided not to receive these items or services.

I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won’t pay.

_____________ _



Signature of patient or person acting on patient’s behalf

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to Medicare, your health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare.

OMB Approval No. 0938-0566 Form No. CMS-R-131-G (June 2002)

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