Advance Beneficiary Notice (ABN)

It is time to complete your Advance Beneficiary Notice of Non-Coverage (ABN), the Medicare form we ask our Medicare aged patients to complete twice each year. This form is required before we can provide services to Medicare aged patients.

To help make your visit quicker and easier, please complete this form before your appointment. If you have any questions or have trouble completing it, no worries — we will be happy to help you when you arrive.

Please choose ONE option:

Option 1: Traditional Medicare/ Part B

Choose this option if you are currently receiving active treatment and would like Clearview Chiropractic to submit your claims to Medicare Part B for possible reimbursement.

Option 2: Medicare Advantage/ Maintenance Care

Choose this option if you wish to receive our services but do not want 
claims submitted to Medicare, are on maintenance/wellness care, have a Medicare Advantage plan, commercial insurance, or are otherwise not seeking Medicare reimbursement.

Option 3:

Choose this option only if you do not wish to receive services.
After selecting your option, please sign, date, and submit the form.

You will also be asked to verify your email address as an added security
measure to help prevent fraud.

Thank you, and we look forward to seeing you soon!