Form – Advance Beneficiary Notice of Noncoverage A. Notifier: Blue Sky Health and WellnessB. Patient Name(Required) C. Identification Number: NPI: 1932521002Advance Beneficiary Notice of Noncoverage (ABN)NOTE: If Medicare doesn’t pay for ___________ 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 ___________ below. Wellness Chiropractic Care Nutritional Supplements Low Level Laser Therapy Lumbar/ Cervical Support All lab work Choose one option for the blank provided.Wellness Chiropractic CareReason Medicare May Not Pay: Estimated CostPlease enter a number from 0 to 9999999.Nutritional SupplementsReason Medicare May Not Pay: Estimated CostPlease enter a number from 0 to 9999999.Low Level Laser TherapyReason Medicare May Not Pay: Estimated CostPlease enter a number from 0 to 9999999.Lumbar/ Cervical SupportReason Medicare May Not Pay: Estimated CostPlease enter a number from 0 to 9999999.All lab workReason Medicare May Not Pay: Estimated CostPlease enter a number from 0 to 9999999.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 __________ 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. 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 Wellness Chiropractic Care 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. 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 Nutritional Supplements 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. 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 Low Level Laser Therapy 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. 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 Lumbar/ Cervical Support 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. 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 All lab work 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:Check only one box. We cannot choose a box for you. OPTION 1: I want the Wellness Chiropractic Care 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. OPTION 2: I want the Wellness Chiropractic Care 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. OPTION 3: I don’t want the Wellness Chiropractic Care listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Check only one box. We cannot choose a box for you. OPTION 1: I want the Nutritional Supplements 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. OPTION 2: I want the Nutritional Supplements 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. OPTION 3: I don’t want the Nutritional Supplements listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Check only one box. We cannot choose a box for you. OPTION 1: I want the Low Level Laser Therapy 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. OPTION 2: I want the Low Level Laser Therapy 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. OPTION 3: I don’t want the Low Level Laser Therapy listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Check only one box. We cannot choose a box for you. OPTION 1: I want the Lumbar/ Cervical Support 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. OPTION 2: I want the Lumbar/ Cervical Support 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. OPTION 3: I don’t want the Lumbar/ Cervical Support listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Check only one box. We cannot choose a box for you. OPTION 1: I want the All lab work 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. OPTION 2: I want the All lab work 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. OPTION 3: I don’t want the All lab work listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. 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.Signature:(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Date Signed(Required) MM slash DD slash YYYY 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.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. 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