Medicare Telehealth ABN Form

Please fill out the applicable information!

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Medicare Telehealth ABN Form

Please fill out the form below and we will get back to you as soon as we can.
A. Notifier
Peak Sports & Spine Physical Therapy
B. Patient Name *
C. Medicare Identification Number *
E-mail *
Physical Therapy via Telehealth
Physical therapy services provided via telehealth are not currently covered by Medicare.
F. Estimated Cost
$100/Evaluation Session $50/Follow Up Session
What You Need To Know:
-Read this notice so you can make an informed decision about your care
-Ask us any questions that you may have after reading
-Choose an option below whether to receive the D. telehealth 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.
G. OPTIONS: Check only one box. We cannot choose a box for you.
Option 1
I want the D. 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 D. telehealth 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 D. telehealth listed above. I understand with this choice, I am NOT responsible for payment and I CANNOT APPEAL TO SEE IF MEDICARE WOULD PAY.
OPTIONS: Please Select 1 Option *
Please choose 1
H. Additional Information:
THIS NOTICE GIVES OUR OPINION, NOT AN OFFICIAL MEDICARE DECISION. If you have any 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 may also receive a copy.
Digital Signature *
By Entering Your Name, This Will Service As Your Digital Signature
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 (03/11) Form Approved OMB No. 0938-0566
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