Printable Medicare Annual Wellness Visit Form

This Form And Its Accompanying Medicare Advantage Annual Wellness Visit Guide May Be Helpful To Follow During Our Medicare Members’ Wellness Visits.

If you’ve used anything in the last year, please list. The guide is available in the clinical resources section of our website under preventive care guidelines. Do you use any recreational drugs? _____ providers involved in your healthcare in an effort to ensure optimal care coordination, please list below all providers you see on a regular basis

This Is For Patients Who Have A Medicare Advantage Plan.

• these visits are preventive health visits and not designed to address chronic existing medical problems. The annual wellness visit is for preventative health and provided by medicare. It asks for information your doctor may want to know about your health over the past year. Take it with you on each visit to your doctor or pharmacist, and whenever you travel away from home.

Medicare Annual Wellness Visit Questionnaire Date:

This is especially important for antibiotics. How well do you handle the stress/anger in your life? Medicare’s “annual wellness visit” (awv) has very specific definitions, limitations and required elements. This is not a visit to evaluate new or ongoing medical problems, and does not cover the management of medical problems such as labs/prescriptions/etc.

*If You Have Completed This Questionnaire Electronically Through.

• complete a medication list and keep the list updated. Please complete this form and bring it with you to your medicare wellness visit (completion of this form by you is required by medicare in order to qualify for free medicare annual wellness visit). • take your medicines until they're gone. • coinsurance and deductibles are waived by medicare for 2 visit charges.