Disclaimer: This form is based on the American Board of Professional Neuropsychology’s (“ABN”) best understanding of Medicare requirements for compliance with the new codes. ABN does not guarantee payment for any services billed, regardless of whether or not the submission is based on this form or any of the related supporting documentation. Billing codes and associated guidance is subject to change at any time and ABN is under no obligation to provide notice of change to the billing codes or associated guidance. ABN’s understanding of billing codes is subject to change at any time, without notice. ABN does not provide any guarantee that the use of this form will prevent Medicare audits, nor does it provide any guarantee with respect to the outcome of a potential Medicare audit. The submission of any invoice to Medicare or other insurances requires the use of professional judgment and discretion and also a full understanding of patient specific facts, circumstances, and treatment with which only the treating practitioner could be conversant. In all circumstances, the treating practitioner is advised to consult Medicare prior submitting any invoice to Medicare. ABN’s provision of this form is not legal advice. ABN disclaims all liability, including liability for damages, consequential damages, and attorney fees for any occurrences, claims, or demands arising from submission of invoices based on the use of this form.