Samples of Advance Beneficiary Notice

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Medicare provides an example Advanced Beneficiary Notice (ABN) that you can use as an example. I have provided web links to the Medicare form below in addition to other online resources on ABN. You can use the Medicare form "as is" or modify it for your specific needs. If you do make any modifications I would recommend that your attorney review the updated form to make sure that the form would be in compliance with the desired outcome. As a reminder, if you use the ABN with a Medicare patient, it must not be modified in any from is downloaded from the Medicare web site. Any alterations for Medicare patients will cause the form to be invalid.

CMS Beneficiary Notices Initiative Web Site www.cms.hhs.gov/BNI/

CMS ABN Form - English www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf

CMS ABN Form - Spanish www.cms.hhs.gov/BNI/Downloads/CMSR131GSpanish.pdf

Empire Medicare Services ABN Guide - 2004 www.empiremedicare.com/traina/manual/pet0300.pdf

ACOFP Article on Advanced Beneficiary Notices https://www.acofp.org/

Mayo Clinic FAQ on Advanced Beneficiary Notice for Patients www.mayoclinic.org/becomingpat-jax/medicare-waiver-abn-faqs.html

Johnson Memorial Hospital FAQ on Advanced Beneficiary Notice for Patients www.johnsonhealthnetwork.com/jmhpiabn.htm

Robert C. Fifer, Ph.D. is currently the Director of Audiology and Speech-Language Pathology at the Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine. He received his B.S. degree from the University of Nebraska at Omaha in Speech-Language Pathology with a minor in Deaf Education. His M.A. degree is from Central Michigan University in Audiology. And his Ph.D. degree is from Baylor College of Medicine in Audiology and Bioacoustics. Dr. Fifer's clinical and research interests focus on the areas of auditory evoked potentials, central auditory processing, early detection of hearing loss in children, and auditory anatomy and physiology. He is the current President of the Florida Association of Speech-Language Pathologists and Audiologists, a member of ASHA's Health Care Economics Committee, and the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee. Additional responsibilities at the state level include serving as a consultant to the Florida Department of Health's Children's Medical Services and the audiology representative to the Genetics and Newborn Screening Advisory Council.