Patient Billing Acknowledgement Form For Non-Covered Services including Maintenance/Wellness and Elective Services

Confusing as it may sound, the standard ABN form ( Advanced Beneficiary Notice) is NOT  needed for services that MEDICARE never covers.  Rather it is used to put your patient on notice that a service MAY NOT be covered.

If you are offering services that you know Medicare, or any other plan will not , this 2 page  form ( one for services, one for products) spells this out so you have a signed attestation that you have notified the patient that this is a non covered service that they will pay for privately without any submission to any carrier for potential partial or full reimbursement.

Downloadable, editable and attorney reviewed.