2016-698 Emergency Svc - North State Medical Transport - Application for Services Franchise by Ordinance

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NORTH STATE North State Medical Transport MEDICAL TRANSPORT 1240 Corporation Pkwy,Raleigh,NC 27610 Phone:(919)261-8911 Fax:(919)261-8991 Patient Name: Social Security Number: Advance Beneficiary Notice of Non-coverage(ABN) 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. Services Reason Medicare May Not Pay: Estimated Cost Medicare does not pay for transportation from a residence or a SNF for Ambulance services that could more economically be performed at the residence or SNF $ transport and mileage _Medicare does not pay for ambulance service that is not medically necessary BLS Ambulance Service BLS _Medicare does not pay for transports to a doctor's office or other non-covered $ per mile destinations $ Ambulance _Medicare does not pay for transports for the convenience of a patient,family ALS Ambulance Service mileage or physician $ ALS Ambulance —Medicare does not pay for mileage beyond the closest appropriate facility $ per mile _Medicare does not pay for a higher level of service(Advanced Life Support) Non-Covered when a lower level of service(Basic Life Support)would suffice Additional Cost Milage 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 wheelchair van or stretcher car services WHAT YOU NEED TO DO NOW: • Read this notice,so you can 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 to use any other insurance that 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 1 also want Medicare billed for an official decision on payment,which is sent to me an a Medicare Summary Notice(MSN). I understand that if Medicare doesn't pay,1 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. Additional Information: This notice gives our opinion,not an official Medicare decision. If you have other questions on this notice or Medicare billing,call 1-880-MEDICARE(1-800-633-4227111Y:1-877-486-2048). Your Signature below means you have received a copy of this ABN and understand this notice. Signature: Date: According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid 0141E control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form,please write In:CMS,7500 Security Boulevard,Attn:PRA Reports Clearance Officer,Baltimore,Maryland 21244-1850. 56