Medicare ABN form

An ABN form is a written notice that Medicare may not, or will not, pay for services or items recommended by your doctor, healthcare provider or supplier. The form includes the items or services that Medicare isn't expected to pay for, the reasons why and an estimate of the costs. An ABN allows you to clearly see your financial liability for the items or services and gives you a chance to determine your options.

Your doctor, healthcare provider or supplier must deliver the ABN form before providing the recommended items or services. In fact, it must be given far in advance so you have time to consider your options without feeling rushed.¹

ABN forms generally provide you with 3 options. Here are the actual options, plus some additional insight:

• 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.
  
  Note: This option allows you to receive the services and/or items and requires your doctor, healthcare provider or supplier to submit a claim to Medicare. You also have the right to appeal the payment decision.


• 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.
  
  Note: This option allows you to receive the non-covered services and/or items and pay for them out of pocket. No claim will be filed, and since Medicare won’t be billed, you won’t have any Medicare appeal rights.


• 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.
  
  Note: This option means you don’t want the care in question. By checking this box, you understand that no services or items will be provided and you won’t have any Medicare appeal rights.

• Medicare ABNs are for Original Medicare only—not Medicare Advantage plans.
• You’ll never receive an ABN for prescription drugs that aren’t covered by your Part D plan.
• Some ABN forms may look different, depending on the provider.

Medicare ABN forms provide you with an opportunity to make informed decisions about your healthcare. For more information on how to fill out the form, check out these ABN form instructions provided by the Centers for Medicare & Medicaid Service (CMS).

To learn more, visit CMS.gov for complete instructions, PDF opens new window.