Who Signs an Advance Beneficiary Notice (ABN)?

The Medicare beneficiary signs an Advance Beneficiary Notice of Noncoverage. If the beneficiary cannot sign because of incapacity, an authorized representative signs on their behalf. The ABN (CMS-R-131) is the form a provider hands you before delivering a service Medicare is expected to deny, and your signature confirms you understand you may owe the bill.¹

One boundary worth stating up front: ABNs only apply to Original Medicare. If you’re in a Medicare Advantage plan, providers cannot use an ABN, and coverage questions go through the plan’s organization determination process instead.²

When Someone Else Can Sign for You

CMS recognizes two categories of representatives who can sign in the beneficiary’s place. An authorized representative already has legal authority to make healthcare decisions under state law, such as a legal guardian or someone named in a durable medical power of attorney. An appointed representative is someone the beneficiary formally designated using CMS Form 1696 or a similar written instrument.³

When neither exists and the beneficiary is temporarily incapacitated, a family member or close friend whom the provider reasonably determines could represent the beneficiary’s interests may sign. CMS advises providers to work with legal counsel on a protocol for these situations, because the choice of who qualifies carries real legal and financial weight.³

A different situation: the beneficiary is mentally competent but physically unable to sign, say a broken hand. The provider can annotate the form on the beneficiary’s behalf, at the beneficiary’s direction, and a second person should witness this whenever possible.³

Does the Provider Sign It

No. The provider (called a “notifier” in CMS terminology) does not sign the ABN. Notifiers include physicians, outpatient hospitals, labs, home health agencies, hospice providers, and medical equipment suppliers. Their obligation is to print their name, address, and phone number at the top of the notice, deliver it before the service, and review it with you and answer questions before you sign. They keep a copy of the signed form on file.¹⁴

What You’re Signing For

Before signing, you have to check one of three option boxes on the form.¹

Option 1: Get the service and have the provider submit a claim to Medicare. You may be asked to pay up front. If Medicare denies, you owe the cost but can appeal. If Medicare pays, the provider refunds you minus any copays or deductibles.
Option 2: Get the service, pay for it yourself, and instruct the provider not to bill Medicare. Because no claim is filed, you cannot appeal.
Option 3: Decline the service. You owe nothing and no claim is filed.

Only Option 1 preserves your appeal rights. The ABN itself is not a coverage denial; it’s a warning. An actual denial arrives later on a Medicare Summary Notice with appeal instructions.⁵

One narrower case: a voluntary ABN issued as a courtesy for services Medicare never covers, like cosmetic surgery or routine dental care. Those are purely informational, and you do not need to check an option box or sign and date the notice.⁶

If You Refuse to Sign

You are not compelled to sign. If you refuse to choose an option or sign, the provider should note the refusal directly on the original form and may list witnesses, though witnesses are not required.⁴

CMS guidance tells providers to consider not delivering the service when a beneficiary refuses to sign, unless withholding it would endanger the patient’s health or expose the provider to civil liability. Refusing to sign does not automatically protect you from a bill if the provider goes ahead. The documented refusal shows you were warned, and that documentation can be used against you in a later payment dispute.⁴

When Your Signature Doesn’t Bind You

A signed ABN doesn’t automatically stick if the notice itself was defective. If the provider failed to give you an ABN when one was required, or delivered a defective one, Medicare’s contractor holds the provider financially liable. The provider cannot collect from you and must refund any money already collected.⁷

Defects include an ABN delivered after the service, a notice that didn’t identify the specific items or services, a missing cost estimate without explanation, or a presentation that didn’t give you a genuine chance to choose. If you think a provider billed you after failing to issue a proper ABN, you can contact your Medicare contractor to dispute the charge.⁷

1
Centers for Medicare & Medicaid Services. Advance Beneficiary Notice of Non-coverage (ABN) Form Instructions
2
Centers for Medicare & Medicaid Services. Advance Beneficiary Notice of Noncoverage
3
Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual – Chapter 30
4
Centers for Medicare & Medicaid Services. Advance Beneficiary Notice of Non-coverage Tutorial
5
Centers for Medicare & Medicaid Services. Medicare Appeals
6
Centers for Medicare & Medicaid Services. Medicare Advance Written Notices of Non-coverage
7
Centers for Medicare & Medicaid Services. ABN CMS Manual Instructions