Form CMS-R-296 Home Health Advance Beneficiary Notice (HHABN)

Home Health Advance Beneficiary Notice (HHABN)
[SAMPLE]
We,
[insert name of HHA]
, your home health agency, are letting you know that we [insert
appropriate clause] with the following items and/or services:
[Describe affected items and/or services]
Because: [Describe appropriate reason]

If you have questions about these changes, you can call us at
TTY users should call (

)

(

)

.

.

INSERT:
OPTION BOX 1 TEXT:
USE WHEN ITEMS AND/OR SERVICES MAY BE PROVIDED THAT WILL NOT BE PAID FOR BY MEDICARE.
OR

OPTION BOX 2 TEXT:
USE WHEN ITEMS AND/OR SERVICES WILL NO LONGER BE PROVIDED FOR FINANCIAL AND/OR OTHER
REASONS.
OR

OPTION BOX 3 TEXT:
USE WHEN PHYSICIAN’S ORDERS REDUCE CERTAIN ITEMS AND/OR SERVICES.

Patient’s Name

Patient Identification

Signature of the Patient or of the Authorized Representative

Date

Please read and sign this notice. Return it to us or mail it to our address listed above.
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 OMB control number for this information collection is 0938-0781. The time required to complete this information collection is estimated to average 5
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 to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form No. CMS-R-296 (08/2012)

OMB Approval No. 0938-0781

Home Health Advance Beneficiary Notice (HHABN)
[Option Box 1 Sample]
, your home health agency, are letting you know that we
with the following items and/or services:

We,

Because:

If you have questions about these changes, you can call us at
TTY users should call (

)

(

)

.

.

The estimated cost of the items and/or services listed above is $
If you have other insurance, please see number 3 below.
You have three options available to you. You must choose only one of these options by checking the box next to
the option and then signing below:
□ 1. I don't want the items and/or services listed above. I understand that I won't be billed
and that I have no appeal rights since I will not receive those items and/or services.
□ 2. I want the items and/or services listed above, and I agree to pay myself since I don't
want a claim submitted to Medicare or any other insurance I have. I understand that I
have no appeal rights since a claim won't be submitted to Medicare.
□ 3. I want the items and/or services listed above, and I agree to pay for the items and/or
services myself if Medicare or my other insurance doesn't pay. Send the claim to
(Please check one or both boxes):
□ Medicare
□ My other insurance:
Please note: If you select option 3 and a claim is submitted to Medicare, you will get a Medicare Summary
Notice (MSN) showing Medicare's official payment decision. If the MSN indicates that Medicare won't pay all
or part of your claim, you may appeal Medicare's decision by following the appeal procedures in the MSN. If
you don't receive a MSN for your claim, you can call Medicare at: 1-800-633-4227. TTY: 1-877-486-2048.
You may have to pay the full cost at the time you get the items and/or services. If Medicare or your other
insurance decides to pay for all or part of the items and/or services that you have already paid for, you should
receive a refund for the appropriate amount.
By signing below, I understand that I received this notice because this Home Health Agency believes Medicare
will not pay for the items/services listed, and so I chose the option checked above.
Patient’s Name

Patient Identification

Signature of the Patient or of the Authorized Representative

Date

Please read and sign this notice. Return it to us or mail it to our address listed above.
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 OMB control number for this information collection is 0938-0781. The time required to complete this information collection is estimated to average 5
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 to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form No. CMS-R-296 (08/2012)

OMB Approval No. 0938-0781

Home Health Advance Beneficiary Notice (HHABN)
[Option Box 2 Sample]
We,

, your home health agency, are letting you know that we
with the following items and/or services:

Because:

If you have questions about these changes, you can call us at
TTY users should call (

)

(

)

.

.

By signing below, I understand that I received this notice because this Home Health Agency decided to stop
providing the items and/or services listed above. The Agency’s decision doesn't change my Medicare
coverage or other health insurance coverage. I can't appeal to Medicare since this Home Health Agency won't
provide me with any more items and/or services; however, I can try to get the items and/or services from
another Home Health Agency.
Please note that there are many different ways to find another Home Health Agency, including by contacting
your doctor who originally ordered home care. You may then ask the new Home Health Agency to bill
Medicare or your other insurance for items and/or services you receive from them.

Patient’s Name

Patient Identification

Signature of the Patient or of the Authorized Representative

Date

Please read and sign this notice. Return it to us or mail it to our address listed above.
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 OMB control number for this information collection is 0938-0781. The time required to complete this information collection is estimated to average 5
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 to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form No. CMS-R-296 (08/2012)

OMB Approval No. 0938-0781

Home Health Advance Beneficiary Notice (HHABN)
[Option Box 3 Sample]
We,

, your home health agency, are letting you know that we
with the following items and/or services:

Because:

If you have questions about these changes, you can call us at
TTY users should call (

)

(

)

.

.

By signing below, I understand that I received this notice because my doctor has
changed my orders and so my home health plan of care is changing. This Home
Health Agency has explained to me that they cannot provide home care without a
doctor’s order.

Patient’s Name

Patient Identification

Signature of the Patient or of the Authorized Representative

Date

Please read and sign this notice. Return it to us or mail it to our address listed above.
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 OMB control number for this information collection is 0938-0781. The time required to complete this information collection is estimated to average 5
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 to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form No. CMS-R-296 (08/2012)

OMB Approval No. 0938-0781