August 2026 Monthly Webinar-ABN_Spanish_508_v2029

ABN_Spanish_508_v2029_Fillable

Pdf Summary

This document is a Spanish-language Medicare “Advance Beneficiary Notice of Noncoverage” (ABN). It informs a beneficiary that Medicare may not pay for a specific item, test, service, or care, and that the patient may be responsible for the cost.<br /><br />The form includes spaces for the patient name, optional ID number, notifier’s name, address, and phone number. It asks the provider to list the item/service, the reason Medicare may deny payment, and the estimated cost.<br /><br />The patient must choose one of three options:<br />1. Receive the item/service and have it billed to Medicare for an official coverage decision. If Medicare denies payment, the patient may be responsible, but can appeal using the Medicare Summary Notice.<br />2. Receive the item/service but not have it billed to Medicare. The patient pays directly and cannot appeal.<br />3. Decline the item/service. The patient owes nothing and cannot appeal.<br /><br />The notice clarifies that it is not an official Medicare decision. It provides Medicare contact information for questions and explains that patients may request accessible formats or file a discrimination complaint. It also includes legal and paperwork reduction disclosures, the CMS form number, OMB control number, and signature/date lines.

Keywords

Medicare

Advance Beneficiary Notice

ABN

noncoverage

Spanish-language form

beneficiary responsibility

coverage decision

estimated cost

appeal rights

CMS form