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A. Notifier: Alaska Digestive and Liver Disease
B. First Name: Middle Initial: Last Name:
C. Identification Number:
NOTE: If Medicare doesn't pay for the D. Office Visit below, you may have to pay.
Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We accept Medicare may not pay for the Office Visit below.
D. OFFICE VISIT
E. REASON MEDICARE MAY NOT PAY:
Not indicated for diagnosis and/or treatment in this case
F. ESTIMATED COST
No More than $600
G. OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the Office Visit 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 MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the Office Visit listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I can not appeal if Medicare is not billed.
OPTION 3. I don't want the Office Visit listed 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
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).
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Signing below means that you have received and understand this notice.You will also receive a copy.
CMS does not discriminate in its program 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 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.
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