Advance Beneficiary Notice of Noncoverage (ABN)

WARWICK COMMUNITY AMBULANCE ASSOCIATION
151 NORTH LANE P.O.BOX 42
LITITZ, PA. 17543
PHONE: (717) 626-1200 FAX: (717) 627-0728

Identification Number: 1992797765

Patient full name

First NameLast Name

NOTE: If Medicare doesn't pay for the ambulance services 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 ambulance services listed below.

Ambulance transport and mileage: Estimated Cost

$921.27 (BLS Ambulance Service)

$16.71 per mile

Reason Medicare May Not Pay:

Medicare does not pay for transportation from a residence or a SNF for services that could more economically be performed at the residence or SNF.
Medicare does not pay for ambulance service that is not medically necessary.
Medicare does not pay for transport to a doctor's office or other non-covered destinations.
Medicare does not pay for transports for the convenience of a patient, family, or physician.
Medicare does not pay for mileage beyond the closest appropriate facility
Medicare does not pay for a higher level of service (Advanced Life Support) when a lower level of service (Basic Life Support) would suffice
Medicare will not pay for air ambulance service if the patient could have been safely transported by ground ambulance.
Medicare does not pay for non-transporting paramedic intercept services.
Medicare does not pay for a wheelchair van or stretcher car services.

WHAT YOU NEED TO DO NOW:

• Read this notice to 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 ambulance services listed above.

Note: If you choose Option 1 or 2, we may help you use any other insurance you might have, but Medicare cannot require us to do this.

OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the ambulance services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co- pays or deductibles.OPTION 2. I want the ambulance services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don't want the ambulance services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

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.

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