These Centers for Medicare and Medicaid Services (CMS) forms are available to download and complete, for patients being transferred from one facility to another.
The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. “Notifiers” include physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B (including independent laboratories), as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A. They must complete the ABN as described below, and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice.
Complete instructions for filling out the CMS required Advance Beneficiary Notice (ABN).
The CMS required Physician Certification Statement (PCS) form to be filled out by the sending facility for any Medicare beneficiary being transported by ambulance.