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Our Newsletter


Advance Beneficiary Notice

 

                      Augmentative Communication Consultants, Inc.                          

 

Beneficiary Name (please print):                   Medicare #

We expect that Medicare will not pay for the item(s) or services that are described below.  Medicare does not pay for all of your health care costs.  Medicare only pays for covered services when Medicare rules are met.  The fact that Medicare may not pay for a particular item or service, does not mean that you should not receive it.  There may be a good reason your Speech Language Pathologist or Doctor recommended this equipment.

 

Items not covered
Extended Warranties or Additional Training Additional batteries Additional Software Additional mounts when purchased with the initial mount Routers or Printers
Environmental Control Units Upgrades Battery Packs, Extra Wheelchair Blocks, when purchased with the additional mount, AC Adapters

Reason not covered
These items are considered additional accessories that are not needed to access the Speech Generating Device.
or
These items are not considered Reasonable or Customary in accordance with Medicare's policy.

 

The purpose of this form is to help you make an informed decision about whether or not you want to receive these services, knowing that you might have to pay for them yourself.

PLEASE CHOOSE ONE OPTION BY CHECKING ONE BOX.  BE SURE TO SIGN AND DATE YOUR CHOICE AND MAIL TO:

 

AUGMENTATIVE COMMUNICATION CONSULTANTS, INC.,  P. O. BOX 731, 

MOON TOWNSHIP, PA  15108

 

 

Option 1.  YES.           I choose to obtain these products or services.

I understand that Medicare will not decide to pay unless I receive the items/services and that you may bill me for the items or services while Medicare is making its decision.  It is my responsibility to pay the bill and you will refund to me any payments I make to you that are due me if Medicare does pay.

If Medicare denies payment, I agree to be personally and fully responsible for the payment. 

In other words, I will pay personally either out of pocket or through any other insurance that I have.  I understand that I can appeal Medicare's decision.
 

Option 2.  NO.           I choose not to obtain these products or services.

I will not receive these items/services.  I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your decision that Medicare will not pay.
 

     Date:   

  Signature of patient or person signing  on patient's behalf

Note:  Your health information will be kept confidential.  Any information that is collected about the patient on this form will be strictly confidential to Augmentative Communication Consultants, Inc.  If a claim is submitted to Medicare, your health information on this form may be shared with Medicare.  Your health information which Medicare sees will be kept confidential by Medicare.

Augmentative Communication Consultants, Inc.       P. O. Box 731        Moon Township, PA  15108