The following is a copy of the Ward Memorial ABN Worksheet, which you may receive for certain lab or x-ray procedures if you have Medicare:

Ward Memorial Hospital
P.O. Box 40     ***     406 S. Gary     ***     Monahans, TX 79756     ***     (432) 943 - 2511

ADVANCE BENEFICIARY NOTICE

Patient's Name: ________________________________
Date:_________________________

Under Section 1862(a)(1) of the Medicare law, Medicare will only pay for services it determines to be reasonable and necessary. Ward Memorial Hospital believes your physician is in the best position to know the clinical assessment needs of his or her patients. In some cases, when your physician orders a specific test or procedure to either detect pre-symptomatic diseases or, as part of a process to help determine what the diagnosis may be, some insurers, including Medicare, will not pay for the test performed. In your case, Medicare is likely to deny payment for the following service(s):

Please list ALL tests that MAY NOT be covered:

Test Description Test Frequency Cost Reason For Denial

Reason Codes: a) usually does not pay for routine / exam lab work
b) does not pay for this service for the provided diagnosis
c) does not pay for lab work at this frequency d) does not pay for tests that do not have FDA approval
e) describe "other" applicable reasons not listed

CAUTION

1 DO NOT SIGN BLANK "ABN" FORMS.

2. Do not sign the "Beneficiary Agreement to Pay" on this ABN form unless the notice above both, (A) specifies the services for which your physician / supplier is predicting that Medicare will likely deny payment and, (B) specifies your physician's / supplier's reasons for making that prediction.

3. Sign and date either the "Beneficiary Agreement to Pay" or the "Beneficiary Refusal to Receive Service at Own Expense". If you refuse to sign either one and you still demand and receive the service anyway, you will be personally responsible for payment.

4. By "personally and fully responsible for payment" we mean that you will have to either pay out of pocket or by any other insurance coverage you may have.

5. Your physician / supplier should give you a copy of this ABN form. Initial here ______ to show your receipt of a copy.

    "BENEFICIARY AGREEMENT TO PAY"
"I have been notified that, in my case, Medicare is likely to deny payment for the services identified above, for the reason stated. I understand that I have the right to decide whether or not to receive the service identified above. I have decided to receive the services. If Medicare denies payment, I agree to be personally and fully responsible for payment. I understand that if the claim is denied, I will receive a bill from Ward Memorial Hospital for the denied services."

PATIENT'S SIGNATURE: _____________________________________ DATE: _____________

    "BENEFICIARY REFUSAL TO RECEIVE SERVICE AT OWN EXPENSE"
"I have been notified by my physician / supplier that he / she believes that, in my case, Medicare is likely to deny payment for the item or service identified above, for reasons stated. I understand I have the right to decide whether or not to receive the item or service identified above. I have decided not to receive the item or service, since I am not willing to be personally responsible for payment."

PATIENT'S SIGNATURE: _____________________________________ DATE: _____________

The above listed patient has refused to sign this ABN, However, the patient still demands the service be provided.
     _________________________     _________________________     ____________________
        Witness (Print Name)                              Signature                                  Date

    _________________________     _________________________     ____________________
        Witness (Print Name)                              Signature                                  Date

Ward Memorial Hospital P.O. Box 40 * 406 S. Gary * Monahans, TX 79756 *** (432) 943 - 2511
ADVANCE BENEFICIARY NOTICE
Patient's Name: ________________________________				Date:_________________________
Under Section 1862(a)(1) of the Medicare law, Medicare will only pay for services it determines to be reasonable and necessary. Ward Memorial Hospital believes your physician is in the best position to know the clinical assessment needs of his or her patients. In some cases, when your physician orders a specific test or procedure to either detect pre-symptomatic diseases or, as part of a process to help determine what the diagnosis may be, some insurers, including Medicare, will not pay for the test performed. In your case, Medicare is likely to deny payment for the following service(s):

Please list ALL tests that MAY NOT be covered:
Test Description			Test Frequency	Cost	Reason For Denial





Reason Codes:		a) usually does not pay for routine / exam lab work b) does not pay for this service for the provided diagnosis c) does not pay for lab work at this frequency		d) does not pay for tests that do not have FDA approval e) describe "other" applicable reasons not listed
CAUTION
1	DO NOT SIGN BLANK "ABN" FORMS.
2.	Do not sign the "Beneficiary Agreement to Pay" on this ABN form unless the notice above both, (A) specifies the services for which your physician / supplier is predicting that Medicare will likely deny payment and, (B) specifies your physician's / supplier's reasons for making that prediction.
3.	Sign and date either the "Beneficiary Agreement to Pay" or the "Beneficiary Refusal to Receive Service at Own Expense". If you refuse to sign either one and you still demand and receive the service anyway, you will be personally responsible for payment.
4.	By "personally and fully responsible for payment" we mean that you will have to either pay out of pocket or by any other insurance coverage you may have.
5.	Your physician / supplier should give you a copy of this ABN form. Initial here ______ to show your receipt of a copy.

"BENEFICIARY AGREEMENT TO PAY" "I have been notified that, in my case, Medicare is likely to deny payment for the services identified above, for the reason stated. I understand that I have the right to decide whether or not to receive the service identified above. I have decided to receive the services. If Medicare denies payment, I agree to be personally and fully responsible for payment. I understand that if the claim is denied, I will receive a bill from Ward Memorial Hospital for the denied services." PATIENT'S SIGNATURE: _____________________________________ DATE: _____________

"BENEFICIARY REFUSAL TO RECEIVE SERVICE AT OWN EXPENSE" "I have been notified by my physician / supplier that he / she believes that, in my case, Medicare is likely to deny payment for the item or service identified above, for reasons stated. I understand I have the right to decide whether or not to receive the item or service identified above. I have decided not to receive the item or service, since I am not willing to be personally responsible for payment." PATIENT'S SIGNATURE: _____________________________________ DATE: _____________
The above listed patient has refused to sign this ABN, However, the patient still demands the service be provided. _________________________ _________________________ ____________________ Witness (Print Name) Signature Date _________________________ _________________________ ____________________ Witness (Print Name) Signature Date