How to use these forms

Submit a referral via fax. Simply open the form by clicking on it, complete all fields, then print for physician’s signature prior to faxing to Bedard Pharmacy and Medical Supplies (207-784-7992). The forms may also be downloaded and saved for future use. Bedard will confirm receipt of your order.

People with original Medicare whose supplier thinks that Medicare probably won't pay for items or service can give a written notice called an "Advance Beneficiary Notice of Non-Coverage" (ABN). This form lists items that Medicare isn't expected to pay for, an estimate of the costs and the reasons why Medicare may not pay. The purpose of the ABN is to give the beneficiary the ability to make informed decisions on whether or not to obtain the products and understand that the beneficiary may be held financially responsible for the product.

There are three options when filling out an ABN. One must be chosen:
  1.  A beneficiary wants the items or services that may not be paid for by Medicare. The provider or supplier may ask the beneficiary to pay for them now, but also want them to submit a claim to Medicare for the items or services. If Medicare denies payment, the beneficiary is responsible for paying, but since a claim was submitted they can appeal to Medicare.
  2. A beneficiary wants the items or services that may not be paid for by Medicare, but does not want the provider or supplier to bill Medicare. The beneficiary may be asked to pay for the items or services now, but because they requested the provider or supplier not submit a claim to Medicare, they cannot file an appeal.
  3. The beneficiary does not want the items or services that may not be paid for by Medicare and they are not responsible for any payments. A claim isn't submitted to Medicare and the beneficiary cannot file an appeal.

An ABN is not an official denial and may be appealed if payment is denied when a claim is submitted.

Referral Forms 1