Proof of Delivery, Return Policy & Authorization to release information & payment of insurance benefits to Foot and Ankle Physicians of Ohio I have received the above product as prescribed by my physician and authorize Foot and Ankle Physicians of Ohio to release to my insurer any needed information for this or a related claim. I request that payment of authorized benefits be made on my behalf and I assign the benefits payable for the medical equipment provided by Foot and Ankle Physicians of Ohio to Foot and Ankle Physicians of Ohio or its affiliates. Although I recognize that I have the primary responsibility for contacting and submitting claims to that my insurer, I have received the equipment and authorize Foot and Ankle Physicians of Ohio to submit a claim to any of the insurers as may be required. I understand I responsible for deductibles and co payments not covered by my insurance. Should my insurance plan not provide coverage in its entirety for any reason, I understand that Iam responsible for payment.
I was hereby given advance notice that Medicare and all other insurance providers do not pay for from medical coverage. I understand that because this item is excluded from medical coverage, I am responsible for payment to Foot and Ankle Physicians of Ohio.
I understand that all items received from Foot and ankle Physicians of Ohio are Non-Returnable, and Non-Refundable
If there is a product deficiency or failure, a replacement product may be available.
Patient/Authorized Signature Your signature on this form indicates that you have received the prescribed product.
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn't pay for D. L1971 AFO Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.L1971AFO below.
Exceeds the frequency in which this type of equipment is covered.
Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading.
Am not responsible for payment, and I cannot appeal to see if Medicare would pay.
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048 Signing below means that you have received and understand this notice. You may ask to receive a copy.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about- us/accessibility-nondiscrimination notice
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response,including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp.01/31/2026)
Form Approved OMB No. 0938-0566
Advance Beneficiary Notice of Non-coverage (ABN)
This notice gives our opinion, not an official Insurance decision.
Signing below means that you have received and understand this notice. You also receive a copy. Signature: Date: