The ABN must clearly identify the service/procedure the surgeon plans to provide and state why Medicare may not provide coverage. The ABN affects only those services/procedures you've specifically listed. You should not give an ABN to a beneficiary if you have no specific, identifiable reason to believe Medicare will not pay. Likewise, you should not give the beneficiary a blank ABN to sign and then fill in the form later.
In all cases, provide the patient with a completed and signed copy of the ABN for his records.
Helpful hint: To obtain a standardized, sample ABN, visit the CMS Web site (www.cms.gov) and use the "search" function to locate form "CMS-R-131-G"