Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for Laboratory Test 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 Laboratory Test below.
Laboratory Test(Required)
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 Laboratory Test 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.
Options(Required)
Check only one box. We cannot choose a box for you.
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.
Date(Required)
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected]