CMS Pub. 100-04, ch. 30, § 50.6

Step-by-step instructions for notice completion are posted along with the notice on the

CMS website and can be downloaded via this link:

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

A. Other Considerations During ABN Completion

1. Beneficiary Changes His/her Mind

If after completing and signing the ABN, a beneficiary changes his/her mind, the notifier

should present the previously completed ABN to the beneficiary and request that the

beneficiary annotate the original ABN. The annotation must include a clear indication of

his/her new option selection along with the beneficiary's signature and date of annotation.

In situations where the notifier is unable to present the ABN to the beneficiary in person,

the notifier may annotate the form to reflect the beneficiary's new choice and

immediately forward a copy of the annotated notice to the beneficiary to sign, date, and

return.

In both situations, a copy of the annotated ABN should be provided to the beneficiary as

soon as possible. If a related claim has been filed, it should be revised or cancelled if

necessary to reflect the beneficiary’s new choice.

2. Beneficiary Refuses to Complete or Sign the Notice

If the beneficiary refuses to choose an option and/or refuses to sign the ABN when

required, the notifier should annotate the original copy of the ABN indicating the refusal

to sign or choose an option and may list witness(es) to the refusal on the notice although

this is not required. If a beneficiary refuses to sign a properly delivered ABN, the notifier

should consider not furnishing the item/service, unless the consequences (health and

safety of the patient, or civil liability in case of harm) are such that this is not an option.

In any case, the notifier should provide a copy of the annotated ABN to the beneficiary,

and keep the original version of the annotated notice in the patient’s file.