Medicare Annual Wellness Visit Forms

Medicare Wellness Visits focus on preventive care, wellness planning, and health risk assessment.

Please complete the following TWO forms prior to your appointment.

Patient Demographic Form Medicare Wellness Questionnaire

If you are unable to submit these forms digitally, they may also be printed and brought to your appointment.

Print Demographic Form Print MCW Questionnaire

For Your Appointment

Please arrive 15 minutes prior to your scheduled appointment time.
Bring your insurance card.
Bring all medications and supplements in their original bottles.

Medicare Wellness Visits focus on preventive care and wellness planning. If additional medical concerns, symptoms, medication changes, chronic condition management, referrals, or treatment plans are addressed during the same appointment, a separate office visit may be billed depending on your insurance benefits.

Questions?

Call 402-488-7400 Text 402-662-6765