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PATIENT FORMS
NEW PATIENT FORMS:

New Patient Information Sheet



WELCOME TO MEDICARE FORMS:
  • "Welcome to Medicare" preventive visit: You can get this introductory visit only within the first 12 months you have Part B. This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed. It also includes:

This visit is covered one time. You don’t need to have this visit to be covered for yearly "Wellness" visits.

  • Yearly "Wellness" visits: If you've had Part B for longer than 12 months, you can get this visit to develop or update a personalized prevention help plan to prevent disease and disability based on your current health and risk factors. Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy and get the most out of your visit. It also includes:
    • A review of your medical and family history
    • Developing or updating a list of current providers and prescriptions
    • Height, weight, blood pressure, and other routine measurements
    • Detection of any cognitive impairment
    • Personalized health advice
    • A list of risk factors and treatment options for you
    • A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.

This visit is covered once every 12 months (11 full months must have passed since the last visit).


Annual Wellness Form


TRANSFER OF RECORDS:

Transfer of Records Form
 
Annual Wellness Form

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