Before giving an Original Medicare patient an item, test or service that Medicare may not pay for, physicians, suppliers, labs, hospitals, home health agencies and hospices use this one-page notice to shift potential financial liability to the patient. The notifier fills in the item, the reason and an estimated cost; the patient picks one of three options and signs. A properly delivered, signed ABN lets the provider bill the patient if Medicare denies.
The notifier (practice, supplier or facility staff) completes the header, patient name, optional identification number, the item, reason and cost table, and any additional information. The patient or a representative chooses one option, then signs and dates; staff may record the choice or the date only when the patient is physically unable and asks.
Put the notifier's name, address and phone number, including a TTY number when needed, at the top right of the notice. It can be part of a logo or be typed, handwritten, pre-printed or added on a label. If the billing entity differs from the notifier, more than one entity may appear here, as long as the Additional information section says whom to contact about billing.
Enter the patient's first and last name, with a middle initial if one appears on the Medicare card. A misspelling or missing initial doesn't invalidate the ABN if the patient recognizes the name. The identification number is optional, for example a medical record or filing number that links the notice to a claim. Never put the Medicare beneficiary identifier or Social Security number on the notice.
List each specific item or service expected to be denied; group descriptions such as 'wound care supplies' are allowed, and repetitive care needs its frequency or duration. Give at least one plain-language reason per item, such as 'Medicare does not pay for this test as often as this.' Enter a good-faith cost estimate for every item; grouped estimates and average daily costs are permitted. Entries should be easy to read, about 12-point type.
The patient chooses one option. Option 1: receive the service and have Medicare billed for an official decision, with appeal rights. Option 2: receive it and pay without a Medicare claim, so no appeal. Option 3: decline it. Never pre-select. Dual-eligible patients must be told to choose Option 1. Suppliers who don't accept assignment strike the last sentence of Option 1 with a single line and add the CMS unassigned claim statement.
Use this space for clarifications that help the patient: whom to call with billing questions when the notifier isn't the billing entity, other coverage such as a Medigap policy, a dated witness signature, or annotations such as 'patient refused to choose an option.' Annotations are assumed to carry the signature date unless dated separately. Non-participating suppliers place the CMS unassigned claim statement here.
Once the patient reviews and understands the notice, the patient or representative signs and dates it; this line can't be completed before the rest of the notice. A representative writes '(representative)' after the signature, with the name legible or printed. Staff may enter the date only if the patient has physical difficulty writing and asks. Then offer the patient a copy of the completed notice.
The disclosure statement must be included with the notice, either on a separate page or on the back of a double-sided ABN. The notice itself must be reproduced on a single page, letter or legal size, and a legal-size page may use the extra space for the Medicare exclusions and cost table.
Download the current version from the source each time; forms change without notice.
Advance Beneficiary Notice of Non-coverage (ABN)
Aviso anticipado de no cobertura para el beneficiario (ABN)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Yes. CMS publishes Form CMS-R-131 in English and Spanish, each in standard, large-print and fillable versions, in one download package on its ABN page. The current notice shows an expiration date of 03/31/2029 and OMB number 0938-0566. Use the version in the language the patient reads so they can make an informed choice.
When you expect Medicare to deny an item or service as not reasonable and necessary, and in other listed cases such as custodial care, home health when the patient isn't homebound or lacks a skilled need, and experimental tests. For care Medicare never covers, such as routine eye, dental or foot care, an ABN is optional and the patient need not choose or sign.
No. The patient or representative must pick exactly one option, and pre-selecting an option invalidates the notice. Staff may mark the patient's choice only when the patient is physically unable and asks, and must annotate the notice to say so. If the patient won't choose, annotate it 'patient refused to choose an option.'
CMS says the notifier should keep the signed ABN on file, generally for 5 years from discharge or completion of care when state law sets no other requirement. A scanned copy in the electronic record is acceptable. If a different entity bills Medicare, such as the lab that tests a specimen you drew, give that entity a copy.