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Medicare Part B Patient Consent Forms

Advance Beneficiary Notice of Noncoverage (ABN)

Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.

Advance Beneficiary Notice of Noncoverage (ABN) Spanish

Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.