Get Nomnc

This guide provides easy-to-follow instructions for filling out the Notice of Medicare Non-Coverage (NOMNC) form online. It is designed to help users understand each section of the form and complete it accurately.

Follow the steps to complete the NOMNC form.

1. Click the ‘Get Form’ button to obtain the NOMNC form and open it in your digital editor.
2. Fill in the name of the facility in the specified field at the top of the form.
3. Provide the facility's address under the address section to ensure proper communication.
4. Enter the facility's telephone number in the designated field for contact purposes.
5. Include the fax number of the facility, if applicable, in the relevant section of the form.
6. Input the patient’s name clearly in the patient name field to identify the individual affected by the notice.
7. Enter the patient’s number accurately to facilitate tracking and reference.
8. Indicate the effective date coverage of current home health services will end in the appropriate section, ensuring the date is clear and legible.
9. Read the section regarding the right to appeal the decision carefully, as it outlines the steps to take if you wish to contest the coverage termination.
10. Follow the instructions for asking for an immediate appeal, ensuring you include any necessary details required by the Quality Improvement Organization (QIO).
11. If needed, refer to additional information or contact details provided for further assistance in the form.
12. Lastly, sign and date the document at the bottom to indicate receipt and understanding of the notice before finalizing your submission.

Complete your documents online to ensure you have everything organized for your records.