Advance Beneficiary Notice of Noncoverage

Read this notice all the way through. Each part explains itself, and you fill in the boxes as you go. You must choose one option in part G and sign in part I before RPhLabs can proceed with testing.

COLA ID 33822 · CLIA ID 45D2288954 · (888) 383-2181 · [email protected]

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A–C · Who is giving this notice, and who it is about

The notifier is the laboratory giving you this notice. Confirm your name exactly as it appears on your Medicare card, and add the identification number from that card.

A. Notifier

B. Patient name(Required)

C. Identification number(Required)

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 item or service listed in part D. below.

D–F · What may not be covered, why, and what it may cost

These three boxes travel together: the item or service, the reason we believe Medicare may deny it, and our good-faith estimate of what you would owe if Medicare does not pay. The estimate is not a bill.

D. Item or service(Required)

E. Reason Medicare may not pay(Required)

F. Estimated cost(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 item or service listed in D. 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.

G · Your options — choose only one

Check only one box. We cannot choose a box for you.

G. Options(Required)

Option 1. I want the item or service listed in D. above, and I want Medicare billed.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 item or service listed in D. 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 item or service listed in D. 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

Anything else we should know, or anything we told you that you want on the record.

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.

I–J · Signature and date

I. Signature(Required)

Sign with your finger, stylus, or mouse.

J. 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].

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 · OMB approval 0938-0566