Our Medicare provider and or health plan have determined that Medicare probably will not pay 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the facility at the top of the form. This is essential for identifying where the services were provided.
3. Fill in the address of the facility, ensuring all details are accurate for correspondence purposes.
4. Provide the telephone number and fax number of the facility to facilitate communication.
5. Enter the patient’s name and patient number in their respective fields to ensure proper identification.
6. Indicate the effective date when coverage for home health services will end. This is crucial for understanding potential financial responsibilities.
7. Review your rights regarding appeal as outlined in the document, ensuring you understand your options if you wish to contest this decision.
8. If you choose to appeal, follow instructions on how to contact your Quality Improvement Organization (QIO) promptly before the effective date.
9. Finally, sign and date the form at the bottom to confirm that you have received and understood this notice.

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