Annual Wellness Assessment (HIPAA)

PATIENT HEALTH OTHER SPECIALTY PHYSICIANS

PLEASE LIST ANY OTHER PHYSICIANS INVOLVED IN YOUR CARE
Gasteroenterologist (Colonoscopy)
Address/Phone
Gynecologist
Address/Phone
Ophthalmologist (Eyes)
Address/Phone
Dermatologist (Skin)
Address/Phone
Dentist
Address/Phone
Urologist
Address/Phone
ANY OTHER PHYSICIANS NOT NOTED ABOVE
Physician Name and Type
Address/Phone
Physician Name and Type
Address/Phone
Physician Name and Type
Address/Phone
Physician Name and Type
Address/Phone

PREVENTATIVE EXAM NOTICE
You have made an appointment for a preventative medical visit. It is your responsibility as the patient to be aware of your insurance benefits. Please understan, we do not work for your insurance company, rather we work 100% for our patients. The recommended treatments and fees we charge will always be baed on the patients' individual needs.

During the exam, if the PCP or the patient discuss a new or existing condition, the insurance will be billed appropriately. Benefit limitations, co-pays and/or deductibles may apply.

I have read and understand the above policy. I acknowledge that I am responsible for any co-pay, deductible, co-insurance charges, and/or non-covered services.
Name*

First NameLast Name
Signature*

Clear
Patient ID (Doctor Use Only)
Should be Empty:

	0 Not at all	1 Several Days	2 More than half the days	3 Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

Annual Wellness Assessment