Voluntary ABN 2019

Voluntary Advance Beneficiary Notice of Noncoverage (VABN)
Notifier

Physical Therapy Studio
B. Patient Name:
C. identification Number:
Voluntary Advance Beneficiary Notice of Noncoverage (VABN)

NOTE: Physical therapy Studio has no relationship with Medicare and is not a

Participating Provider with Medicare, and that Medicare will not cover services

rendered at Physical Therapy Studio.

Physical Therapy Studio can accept self-payments from a Medicare Beneficiary if it is

for a service that would not be covered by Medicare. “Non-covered” services may

include “prevention, wellness, fitness”,maintenance services, or specific service not

available elsewhere by a participating medicare provider.Then a Physical Therapy Clinic or

Studio can collect out of pocket payments from the beneficiary; but only in those

If you are not at this clinic due to a specific pain/injury/dysfunction, but rather to

maintain a certain level of wellness/strength/fitness or prevent issues such as falls or

health decline, then Physical Therapy Studio will be able accept out-of-pocket payments.

Medicare will not be billed for this service .

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 will not pay for the

D. Prevention, wellness, fitness”,maintenance services or specific service not available elsewhere by a

participating medicare provider.

E. Reason Medicare May Not Pay: Non covered service
- • Choose an option below about whether to receive the D. listed above.
G. OPTIONS: Check only one box. We cannot choose a box for you.
Options for care please choose one

OPTION 1. I don’t want the D. listed above ie. “Prevention, wellness, fitness”, ormaintenance services or specific service not available elsewhere by a participatingmedicare provider. I want Physical Therapy for a specific pain/injury/dysfunction. Iwant to use Medicare and understand Physical Therapy Studio has no relationship with Medicare and these services are not covered at Physical Therapy Studio. I have received contact information options for other Physical Therapy Practices in the area that have a relationship with Medicare and will follow up with my care elsewhere.OPTION 2. I want the D. listed above ie. “Prevention, wellness,fitness”,maintenance services or specific service not available elsewhere by aparticipating medicare provider, but do not bill Medicare. I understand PhysicalTherapy Studio’s policy of receiving payment at time of service, and I amresponsible for payment. Medicare is not billed. I understand with this choice I am responsible for payment, and I cannot appeal to see if Medicare would pay.OPTION 3. I don’t want the D.listed above ie. “Prevention, wellness, fitness”, or maintenance services or specific service not available elsewhere by a participating medicare provider.I am refusing care from Physical Therapy Studio at this time.
Signature

Clear
Date

MonthDayYear
Date
This notice gives our opinion. 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 received a copy.
Should be Empty:

Voluntary Advance Beneficiary Notice of Noncoverage (VABN)

Notifier