Medicare Annual Wellness Visit printable pdf download

Medicare Annual Wellness Visit

Windsor Regional Medical Associates

300A Princeton Hightstown Road

Suite 102

East Windsor NJ 08520

609 490-0095, fax 609 490-0091

MEDICARE ANNUAL WELLNESS VISIT FORM

Name _______________________________________________

Date________________

The Medicare Annual Wellness Visit (“AWV”) is meant to review your health status,

update preventive care measures, and develop a plan for your continued good

health. Medicare allows this visit once every 12 months.

By Medicare regulations, this Annual Wellness Visit does not include a

complete physical examination or the evaluation or management of your

other health problems. If provided, these services are billed separately.

During today’s visit:

Do you want a complete physical examination?

Yes

Do you want to address your specific health issues? Yes

Please list the names and specialty of all the other doctors that you see

(You may use the back for additional names)

Name

Specialty

___________________________________ __________________________

___________________________________ ___________________________

Please list any over the counter medications you are taking:

_____________________

________________________ ______________________

_____________________

________________________ _______________________

Please list the names and doses for ALL prescription medications that you have

(even if they are only taken “as needed”). Use the back if needed.

______________________ _______________________ ________________________

Medicare Annual Wellness Visit