Preventive Wellness Visit Form printable pdf download

Preventive Wellness Visit Form

Dear Doctor,

Gordon Food Service (GFS) has launched a wellness program, LiveWell, that

encourages and supports a healthy lifestyle. This is a voluntary program that

requires an annual preventive/routine visit to their doctor. The visit is to create a

relationship with a doctor, gather biometric numbers and begin to set goals to

improve their personal health status.

Your patient has decided to participate in the LiveWell program with GFS. The

program requires an annual preventive wellness visit and to have height, weight,

and blood pressure measures reported. Blood work such as a lipid profile or

blood glucose is optional to report if it is within the scope of care that you are

delivering to your patient.

The Preventive Wellness Visit form has been provided to collect the information

needed for the program. Once the form is completed, it can be securely faxed or

mailed to WellNow by you or your patient. WellNow is a third party that GFS

uses to assist with data collection and reporting.

The Gordon Food Service Health Plan covers Health Maintenance Exams, lipid

profiles and HgA1c testing at 100% when billed with a routine preventive

diagnosis. Covered procedure codes include:

 Health maintenance exam procedure codes in conjunction with a routine

preventive diagnosis: 99384, 99385, 99386, 99387, 99394, 99395, 99396

and 99397

 Cholesterol and HgA1c procedure codes in conjunction with a routine

preventive diagnosis: 80061, 82465, 83718, 83721 and 84478.

Thank you for your partnership in this process. If you have any questions, please

contact the WellNow customer service department at 866-345-9355.

To Good Health,

The WellNow Team and Gordon Food Service Benefits Team

WellNow, LLC 3160 Tremont Avenue Trevose, PA 19053

Preventive Wellness Visit Form