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ABN Form - Capital Women's Care Howard County

ABN Form - Capital Women's Care Howard County 2025

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The document is an Advance Beneficiary Notice of Noncoverage (ABN) from Capital Women’s Care, informing patients that Medicare may not cover certain medical services. It outlines specific services, their costs, and provides options for patients to choose whether they want the services billed to Medicare or paid out-of-pocket. The notice emphasizes the importance of understanding potential financial responsibilities and includes contact information for further inquiries.

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Click ‘Get Form’ to open the ABN Form in our editor.
Begin by entering your Patient Name and Identification Number at the top of the form. This information is essential for identifying your records.
Review the services listed under 'Reason Medicare May Not Pay' and their estimated costs. Ensure you understand each service before proceeding.
Select one option from the provided choices (Option 1, Option 2, or Option 3) regarding your preference for billing Medicare. Check only one box as instructed.
In the 'Additional Information' section, feel free to reach out if you have questions about this notice or Medicare billing.
Finally, sign and date the form at the bottom to confirm that you have received and understood this notice.

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