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Advance Beneficiary Notice
Medicare Beneficiaries:

COS Medical Supplies, Inc. is not a enrolled in Medicare, therefore, Medicare may not reimburse you for any supplies you buy from us. Please read the form below and choose one option.

There are three types of Durable Medical Equipment (DME) suppliers. The one you choose affects how much your costs will be.
    1. Suppliers who are enrolled and "participating" in Medicare must bill Medicare and accept assignment (the Medicare-approved amount) as payment in full. You can only be billed 20 percent of that amount (plus any unmet portion of your Part B deductible).
    2. Suppliers who are enrolled but "not participating" in Medicare are not required to accept assignment. They are allowed to charge you their standard rate and can ask for payment up front. Medicare will then reimburse you for 80 percent of its approved amount, and you pay the balance.

    3. Suppliers who are not enrolled in Medicare are not required to bill Medicare. You may have to submit the claim to Medicare yourself. These suppliers are allowed to charge you their standard rate and can ask for payment up front. Medicare may then reimburse you for 80 percent of its approved amount, and you pay the balance.

    Note: You must go to an enrolled supplier to get coverage for medications, diabetes supplies and capped rental items.

The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.

PLEASE CHOOSE ONE OPTION

YES. I want to receive these items and return to Check Out.

I understand that COS Medical Supplies, Inc. is not enrolled and will not submit a claim to Medicare and that I will not be able to appeal COS Medical Supplies, Inc. opinion that Medicare won't pay.

NO. I have decided not to receive these items and would like to exit Check Out.

I will not receive these items. I understand that COS Medical Supplies, Inc. will not submit a claim to Medicare and that I will not be able to appeal COS Medical Supplies, Inc. opinion that Medicare won't pay.

 
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