August 2026 Monthly AFCNA Webinar-ABN_Spanish_508_v2029

ABN_Spanish_508_v2029_LARGEPRINT

Pdf Summary

This document is the Spanish version of the Medicare <strong>Advance Beneficiary Notice of Noncoverage (ABN)</strong> form. It informs a patient that <strong>Medicare may not pay</strong> for a specific item, test, service, or care, and that the patient may be responsible for the cost.

The form includes spaces for the <strong>patient name</strong>, <strong>ID number (optional)</strong>, <strong>notifier/provider information</strong>, the <strong>item/service in question</strong>, the <strong>reason Medicare may not pay</strong>, and the <strong>estimated cost</strong>.

It asks the patient to choose <strong>one of three options</strong>:
1. <strong>Receive the service and have it billed to Medicare</strong> for an official payment decision. If Medicare denies payment, the patient may be responsible, but can appeal.
2. <strong>Receive the service without billing Medicare</strong>. The patient pays now and <strong>cannot appeal</strong> Medicare’s decision because Medicare is not billed.
3. <strong>Decline the service</strong>. The patient owes nothing and cannot appeal.

The notice explains that it is <strong>not an official Medicare decision</strong>, and provides Medicare contact information for questions. It also states the patient has the right to receive accessible formats such as <strong>large print, braille, or audio</strong>, and may file a discrimination complaint if needed.

The document ends with a <strong>Paperwork Reduction Act disclosure</strong>, explaining the legal basis, estimated completion time, and OMB control number for the form.

Keywords

Medicare

ABN

Advance Beneficiary Notice

noncoverage

Spanish form

patient responsibility

service billing

appeal rights

estimated cost

OMB control number