The revised ABN can be found at:
The ABN is composed of five sections and 10 blanks, which must appear in the following order from top to bottom on the notice:
Notifier (A)
*      Provider must place his name, address and telephone number at the top of the notice.
*      If the billing and notifying entities are not the same, the name of more than one entity may be given in the notifier area.
Patient Name (B)
*      Provider must enter first and last name of the beneficiary receiving the notice. The middle initial should also be used if there is one on the beneficiary’s Medicare card.
Identification Number (C)
*      Medicare numbers or Social Security numbers must not appear on the notice.
Body (D)
*      Providers must list the specific items or services believed to be non-covered in the blank of the note as well as in the first block of the table.
*      In the case of partial denials, providers must list in the blank the excess component(s) of the item or service for which denial is expected.
Table (D, E, F)
*      First Block (D).
                o Providers must list the specific items or services believed to be non-covered.
*      Reason Medicare May Not Pay (E).
                o Providers must explain in beneficiary-friendly language why they believe the items or services may not be covered by Medicare. Commonly used reasons for non-coverage are:
*      “Medicare does not pay for this test for your condition.”
*      “Medicare does not pay for this test as often as this (denied as to frequency).”
*      “Medicare does not pay for experimental or research use tests.”
Note: To be a valid ABN, there must be at least one reason applicable to each item or service listed. The same reason for non-coverage may be applied to multiple items.
Estimated Cost (F).
                o Provider must complete the Estimated Cost blank to ensure the beneficiary has all available information to make an informed decision about whether to obtain potentially non-covered services.
o Providers must make a good faith effort to insert a reasonable estimate for all the items or services listed. In general, we would expect the estimate be within $100 or 25 percent of the actual costs, whichever is greater. Examples of acceptable estimates would include, but not be limited to the following:
*      For a service that costs $250:
                o “Between $150–$300.”
     o  “No more than $500.”
Multiple items or services that are routinely grouped can be bundled into a single-cost estimate.
Options 1, 2 or 3
The beneficiary or his representative must choose only one of the three options listed.
Option 1:
                o This allows the beneficiary to receive the item or services at issue and requires the provider to submit a claim to Medicare. This will result in a payment decision that can be appealed.
Option 2:
                o This option allows the beneficiary to receive the non-covered items or services and pay for them out-of-pocket. No claim will be filed and Medicare will not be billed. Therefore, there are no appeal rights associated with this option.
o Providers will not violate mandatory claims submission rules under 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiary’s written request when selecting this option.
Option 3:
                o This option means the beneficiary does not want the care in question. By checking this box, the beneficiary understands that no additional care will be provided and, thus, there are no appeal rights.
Additional Information (H)
Providers may use this space to provide additional clarification they believe will be of use to beneficiaries. For example:
*      A statement advising the beneficiary to notify his provider about certain tests that were ordered but not received.
*      An additional dated witness signature.
*      Other necessary annotations:
                o Annotations will be assumed to have been made on the same date as that appearing with the beneficiary’s signature.
Signature Box (I, J)
Once the beneficiary reviews and understands the information contained in the ABN, the Signature Box is to be completed by the beneficiary or representative.
                o The beneficiary or representative must sign the notice to indicate that he received the notice and understands its contents. If a representative signs, he should indicate “representative” after his signature.
                o The beneficiary or representative must write the date he signed the ABN. If the beneficiary has physical difficultly writing and requests assistance in completing this blank, the date may be inserted by the provider.