WEA ABN Form

Name: Woodlands Eye Associates – Medical Plaza
Address: 1001 Medical Plaza Dr, Ste 100, The Woodlands, TX, 77380, US
Price range: $000 - $300

Choose Your Office*
(B) Patient Name*
First Last
(C) Identification Number*

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If Medicare doesn’t pay for (D)(*) 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 (D)(*)below.

*(D)*	(E) Reason Medicare May Not Pay:	(F) Estimated Cost:
Refraction(*)	Medicare will not pay for the refraction part of an eye exam. Anything not covered by Medicare becomes the patient’s responsibility unless the service is covered by a supplemental insurance.	$39.00
OCT Scan done same day as Optomap digital photos with same diagnosis. We discount the OCT Scan to $25.00 to avoid an additional office visit charge.	Medicare will not allow OCT Scan and Photos to be billed same day.	$25.00

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 (D)(*) 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.

Please check only one box below.*
- OPTION 1. I want the (D)(*)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 (D)(*) 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 (D)(*) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
(H) Additional Information:

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*
Patient
If you are signing as a personal representative of the patient, please indicate your relationship below.
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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. 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 (03/08) Form Approved OMB No. 0938-0566
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ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

$39.00

$25.00

WHAT YOU NEED TO DO NOW:

(H) Additional Information: