Form No Cms R 131 G PDF Details

When navigating the complexities of Medicare coverage, individuals may encounter situations where they must make informed choices about their healthcare services, especially when coverage is uncertain. At the heart of these situations is the No CMS R 131 G form, officially known as the Advance Beneficiary Notice (ABN). This critical document serves as a communication tool between healthcare providers and patients, notifying patients when Medicare is expected not to cover certain items or services. The essence of the ABN is to empower patients with the knowledge and freedom to decide whether to proceed with services that Medicare may not pay for, understanding the financial responsibilities that might ensue. It outlines the specific items or services in question, the reasons Medicare may deny payment, and the estimated costs involved, allowing patients to make informed decisions about their care. By presenting two clear options, patients can choose to either accept the services and potentially bear the costs or decline the services to avoid charges Medicare is likely not to cover. Additionally, the form includes provisions for appealing Medicare's decisions, emphasizing the importance of patient rights and the confidentiality of health information throughout the process. This form underscores the principle that while not all healthcare costs are covered by Medicare, patients have a right to understand their options and obligations fully.

Form NameForm No Cms R 131 G
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesabn form medicare 2020 pdf, abn form, printable medicare abn form 2020, printable abn forms

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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