OMB Approval No. 0938-0781 Home Health Advance Beneficiary Notice We, _____(INSERT NAME OF HHA)______________________________, your home health agency, are letting you know that we______(INSERT APPROPRIATE CLAUSE) with the following items __ and/or services:_(DESCRIBE AFFECTED ITEM(S) AND/OR SERVICE(S))________ __________________________________________________________________________ __________________________________________________________________________ Because: ___(DESCRIBE APPROPRIATE REASON ) ________________________________________ __________________________________________________________________________ If you have questions about these changes, you can call us at (____) ___________________ TTY users should call (____) _______________. INSERT: OPTION BOX 1 MEDICARE TEXT: USE WHEN ITEM(S) AND/OR SERVICE(S) MAY BE PROVIDED THAT WILL NOT BE PAID FOR BY OR OPTION BOX 2 TEXT: OTHER REASONS. USE WHEN ITEM(S) AND/OR SERVICE(S) WILL NO LONGER BE PROVIDED FOR FINANCIAL AND/OR OR OPTION BOX 3 TEXT: USE WHEN PHYSICIAN'S ORDERS REDUCE CERTAIN ITEM(S) AND/OR SERVICES Patient's Name Signature of the Patient or of the Authorized Representative Medicare # (HICN) Date Please read and sign this notice. Return it to us or mail it to our address listed above. Form No. CMS-R-296 (08/31/2009) SAMPLE American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval No. 0938-0781 Home Health Advance Beneficiary Notice We, ________________________________________________, your home health agency, are letting you know that we_____________________________________________ with the following items and/or services:_________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Because: __________________________________________________________________ __________________________________________________________________________ If you have questions about these changes, you can call us at (____) ___________________ TTY users should call (____) _______________. The estimated cost of the items and/or services listed above is $ _______________________ ___________________________________________________________________________ If you have other insurance, please see #3 below. You have three options available to you. You must choose only one of these options by checking the box next to the option and then signing below: 1. I don't want the items and/or services listed above. I understand that I won't be billed and that I have no appeal rights since I will not receive those items and/or services. 2. I want the items and/or services listed above, and I agree to pay myself since I don't want a claim submitted to Medicare or any other insurance I have. I understand that I have no appeal rights since a claim won't be submitted to Medicare. 3. I want the items and/or services listed above, and I agree to pay for the items and/or services myself if Medicare or my other insurance doesn't pay. Send the claim to (Please check one or both boxes): Medicare My other insurance: ____________________________________________ Please note: If you select option 3 and a claim is submitted to Medicare, you will get a Medicare Summary Notice (MSN) showing Medicare's official payment decision. If the MSN indicates that Medicare won't pay all or part of your claim, you may appeal Medicare's decision by following the appeal procedures in the MSN. If you don't receive a MSN for your claim, you can call Medicare at: (___) ___________. TTY: (___) __________. You may have to pay the full cost at the time you get the items and/or services. If Medicare or your other insurance decides to pay for all or part of the items and/or services that you have already paid for, you should receive a refund for the appropriate amount. By signing below, I understand that I received this notice because this Home Health Agency believes Medicare will not pay for the items/services listed, and so I chose the option checked above. Patient's Name Signature of the Patient or of the Authorized Representative Medicare # (HICN) Date Please read and sign this notice. Return it to us or mail it to our address listed above. Form No. CMS-R-296 (08/31/2009) OPTION BOX 1 American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval No. 0938-0781 Home Health Advance Beneficiary Notice We, ________________________________________________, your home health agency, are letting you know that we ____________________________________________ with the following items and/or services:_________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Because: __________________________________________________________________ __________________________________________________________________________ If you have questions about these changes, you can call us at (____) ___________________ TTY users should call (____) _______________. By signing below, I understand that I received this notice because this Home Health Agency decided to stop providing the items and/or services listed above. The Agency's decision doesn't change my Medicare coverage or other health insurance coverage. I can't appeal to Medicare since this Home Health Agency won't provide me with any more items and/or services; however, I can try to get the items and/or services from another Home Health Agency. Please note that there are many different ways to find another Home Health Agency, including by contacting your doctor who originally ordered home care. You may then ask the new Home Health Agency to bill Medicare or your other insurance for items and/or services you receive from them. Patient's Name Signature of the Patient or of the Authorized Representative Medicare # (HICN) Date Please read and sign this notice. Return it to us or mail it to our address listed above. Form No. CMS-R-296 (08/31/2009) OPTION BOX 2 American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval No. 0938-0781 Home Health Advance Beneficiary Notice We, ________________________________________________, your home health agency, are letting you know that we ____________________________________________ with the following items and/or services:_________________________________________________ __________________________________________________________________________ _________________