Use this form if you think Medicare will not cover a service you are about to perform on a patient covered by Medicare. If the patient still wants the treatment, their signature shows they know they may be responsible for payment. Please note that a separate form must be signed for each service for each date of service, and that the patient has the option to refuse the service. Because of the specificity required, this process (and form) is best managed by the clinical team, instead of the front office. This form was created by the Center for Medicare and Medicaid Services (formerly the Health Care Financing Administration) for your use. For more information, visit http://www.hcfa.gov/medlearn/refabn.htm.
http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp