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Home ยป Advance Beneficiary Notice of Noncoverage Online Form

Advance Beneficiary Notice of Noncoverage Online Form

  • Advance Beneficiary Notice of Noncoverage (ABN)

  • NOTE: If Medicare doesn't pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need_ We expect Medicare may not pay for the D. below
  • D.

    Optomap Retinal Photos
    Frame Lenses Contact Lens Fitting
    Contact Lenses
  • E. Reason Medicare May Not Pay

    Non covered procedure
    Non covered procedure
    Non covered item
    Non covered item
    Non covered procedure
    Non covered item
  • F. Estimated Cost


    • Read this notice, so you can make an informed decision about your care.
    • Ask us any questions that you may have after you finish reading.
    • Choose an option below about whether to receive the D. 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.
  • 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).
    Signing below means that you have received and understand this notice. You also receive a copy.
  • MM slash DD slash YYYY
  • 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.

At this time our office is mask optional for patients and staff. Dr. Gore will continue to wear a mask in the exam room. If you would be more comfortable with our staff fully masking, please let us know when you schedule your appointment and we will be happy to do so.

We ask that if you or someone in your household is ill that you please reschedule your appointment.

  • We have implemented patient, staff screening protocols. Patients are required to wash their hands upon entering the office. Staff will sanitize every staff and patient contact area before and after each patient.
  • If you need to select new glasses or have glasses repaired we ask that you call first.
  • Patients under 18 years old may be accompanied by one parent.