Annual Wellness Visit Form 2016
|
|
- Muriel Mills
- 6 years ago
- Views:
Transcription
1 Annual Wellness Visit Form 6 Initial G48/Subsequent G49 (circle one) Subjective: Past Medical History (mark X to confirm and note duration for chronic conditions only) Conditions Yrs Conditions Yrs Others: Medication Review Last 6 Months (reviewed 59F/reviewed & reconciled 6F) Taken Taken Other Drugs Taken Drug Name For Drug Name For List: For Allergies: Social History (including diet and physical activities): Pertinent Family History: Substance Abuse (Drug/Alcohol): Discussion of Advance Directive: Yes No Comment: (Disscussion Code58F/Plan present in medical record Code57F) List of Specialist involved in member's medical care: Eye Care Professional Gastroenterologist Send Completed Form to Fax: (56) Rev. 5/6
2 Vital Signs: BP: Temp: Ht: Wt: BMI: Pulse Ox: egfr: Physical Examination Normal Abnormal Describe Findings General Skin HEENT Neck Heart Lungs Abdomen Musculoskeletal Neurologic (Consider RAPID PC + PHQ9) Vascular Lymphatic Extremities Rectal/GU Individual Care Plan: Indicate whether the patient needs the item (Yes) or if they have already had it (No) and the date received. Keep form on file and provide member with a copy. Social Marital Status: Married Divorced Single Transportation: Yes No Caregivers: Yes No Living Arrangements: Yes No Recreational Activities: Yes No Tobacco Cessation Date: / / Tobacco Cessation Counseling (ICD F7., CPT G46 (cessation counseling) Pain Screening Pain severity quantified: Yes pain present (5F) Pain severity quantified: No pain present (6F) Nutrition BMI (Code Z68.XX) : Hemoglobin: Serum Albumin: Recent Weight Change: Yes No Dentures: Yes No
3 Functional Status Assessment (code 7F) (does patient need assistance with:) Ability to Take Medication: Yes No Patient getting refills on time?: Yes No Feeding: Yes No Grooming: Yes No Toileting: Yes No Continence: Yes No Ambulation: Yes No Risk for Falls: Yes (codef) No (code F) Bladder Incontinence: Yes No if yes Treatment within past 6 months: Psychological Assessment Feeling Down: Yes No Sleep Disturbance: Yes No History of Depression: Yes No Substance Abuse: Yes No Advance Direction on File: Yes No (F) Cognitive Functioning Oriented: Yes No Immediate Recall: Good or Poor Delayed Recall: Good or Poor Confused: Mostly At times Not at all Memory Deficit: Yes No Inappropriate Behavior: Yes No Ask patient to draw hands to read minutes after 8 (or minutes after ). Case Management/Coordination Risk of admission to hospital: Yes No Risk of placement to SNF: Yes No Referral to Case Mgmt.: Yes No Referral to Disease Mgmt.: Yes No
4 Preventive Screening Checklist check if patient needs the Tx Date (Yes), If they have had the Tx, check Needs? Done Frequency (No), and indicate date performed Yes No (Req'd) Flu Vaccine (Current G8/previously 44F) / / Yearly between Sept. - March Pneumonia Vaccine (all > age 65) / / Once a lifetime (current:g9/previously G848) Glaucoma screening (> age 65 code Z.5) / / Yearly by eye professional Colonoscopy screening: (all > age 5) / / FOBT(Fit Test): annually(code Z.) OR / / Flex Sig(code G4): every 4 yrs OR / / Colonoscopy(code G5): every yrs Prostate Cancer Screen(Digital or PSA) / / Annually (male > age 5) Patients 65 yrs and older: Ask if they have urinary problems / incontinence / / Annually and advised or refer as appropriate Abdominal Aortic Aneurysm (AAA) Screening (Male members 65 and older / / Once in a lifetime who have smoked > cigarettes in a lifetime, have CV, and family history) Abdominal Ultra Sound Female Only Bone density test(dexa SCAN) (female>67 with fracture) 6 months / / Once every yrs for patients at risk for after hip fracture OR on medication osteoporosis. to treat or prevent osteoporosis. Mammogram (Age 5-74) years, (Z.) Yes (G) No Date or Not Applicable Member with Cardiovascular Disease Patients with cardiovascular conditions. LDL-C in Current Year (control < mg/dl) / / Annually On beta blockers for at least 6 months from discharge if hospitalized and / / Annually discharged with diagnosis of AM previous - current year Member with Diabetes HbAC lab (control < 7.)(code 48F-5F) / / Annually Retinal eye exam (code F-4F) / / Annually LDL-C lab(control < mg/dl)48f-5f / / Annually Blood Pressure < 4/9 (74F-78F) / / Each Visit Micro albumin test in current year OR patient on ACE or ARB in previous year / / Annually 4
5 Members with Hypertension Blood Pressure < 4/9 (74F-78F) / / Each Visit Member with Rheumatoid Arthritis Patients with diagnoses of RA trial of (DMARDs) / / On RA meds Members with COPD Spirometry test to confirm diagnosis / / Yearly PHQ9 Risk for Depression Screening: Please complete the following questionnaire. Over the last two weeks, how often have you been More than bothered by any of the following problems? None Several half the Nearly every (Circle number to indicate your answer) days days day. Little interest or pleasure in doing things. Feeling down, depressed, or hopeless. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself - or that you are failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the Newspaper or watching television 8. 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 9. Thoughts that you would be better off dead, or of hurting yourself in some way add columns: (Healthcare Professional: For interpretation of TOTAL, TOTAL:. If you checked off any problems, how Not difficult at all difficult have these problems made it for Somewhat difficult you to do you work, take care of things at Very difficult home, or get along with other people? Extremely difficult Depression Severity by Total Score: -4 Minimal 5-9 Mild -4 Moderate 5-9 Moderately Severe -7 Severe *75F Depression Screening *F. major depressive disorder, single episode, mild * F.8 other depressive episodes * F. MDO, single episode, moderate *F.9 MOD, single episode, unspecified * F. MDO, single episode, severe without psychotic features *F. MDO, single episode, severe with psychotic features 5
6 ICD Code or Diagnostic Description Assessment Planning Provider Signature and Credential: Date: Send Completed Form to Fax: (56)
Medicare & Dual Options Annual Comprehensive Exam FAX COMPLETED FORM TO: Patient Personal Information
FAX COMPLETED FM TO: 877-682-2216 All fields marked with an * are required to be completed in order to receive payment for the ACE Form, unless indicated otherwise. Please refer to the document titled
More informationo Normal Balanced Diet for your Age o High in Carbohydrates o High in Fats o High in Protein o Other Diet
HEALTH ASSESSMENT SCREENING FORM GO402 Welcome to G0438 First Annual G0439 Subsequent Other Code PATIENTS NAME: DATE OF BIRTH: DATE OF SERVICE: PLEASE LIST CURRENT MEDICATION, ALSO OVER THE COUNTER MEDICATIONS
More informationMedicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
More informationTo: Our Medicare Patients. Subject: Your Welcome to Medicare Exam
To: Our Medicare Patients Subject: Your Welcome to Medicare Exam Medicare covers a one-time Welcome to Medicare visit. The Welcome to Medicare visit must occur during your first twelve months as a Medicare
More informationPATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION
PATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION USING PHQ-9 DIAGNOSIS AND SCORE FOR INITIAL TREATMENT SELECTION A depression diagnosis that warrants treatment or treatment change, needs at least one
More informationWELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
More informationSchodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
More informationDANA COKER KINGDON, PA
PERSONAL HEALTH HISTORY AGNES KINRA, MD, PA Board Certified in Internal Medicine DANA COKER KINGDON, PA 4104 West 15 th St # 101 Plano, TX 75093 Phone 972-596-0006 Fax 972-596-0904 Name (Last, First, M.I.):
More informationPlease complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
More informationAppendix B: Screening and Assessment Instruments
Appendix B: Screening and Assessment Instruments Appendix B-1: Quick Guide to the Patient Health Questionnaire (PHQ) Purpose. The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition
More informationMedicare Annual Wellness Visit HEALTH RISK ASSESSMENT
Patient Name: Date of Birth: GENERAL HEALTH 1. How is your overall health? Excellent Good Fair Poor 2. How many different prescriptions are you taking? 0-3 4-6 7-10 10+ 3. Do you take all of your mediations
More informationMEDICARE ANNUAL WELLNESS VISIT
MEDICARE ANNUAL WELLNESS VISIT FAMILY MEDICINE CENTERS OF SOUTH CAROLINA, LLC Springwood Lake Midtown Woodhill Saluda Pointe Lake Murray Name: Ethnic Background: Race: Age: Sex: Marital Status: PLEASE
More informationBrief Pain Inventory (Short Form)
Brief Pain Inventory (Short Form) Study ID# Hospital# Do not write above this line Date: Time: Name: Last First Middle Initial 1) Throughout our lives, most of us have had pain from time to time (such
More informationSTEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP
More informationPHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
More informationSoutheastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
More informationDr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, DNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
More informationDr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, FNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
More informationCBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
Patient Information CBT Intake Form Patient Name: Preferred Name: Last Date of Birth: _// Age: _ First MM DD YYYY Gender: Best contact phone number: Email address: _ Address: _ Primary Care Physician:
More informationRN Behavioral Health Care Manager in Primary Care Settings
RN Behavioral Health Care Manager in Primary Care Settings Integrated Care and the Expanding Role of Nurses Seattle Airport Marriott, SeaTac, WA Tuesday, January 9, 2018 The Healthier Washington Practice
More informationSec on 1 Demographic Informa on
The Priority Care Center A Program of the Humboldt IPA Primary Care Physician: Sec on 1 Demographic Informa on How were you referred: Name (Last, First, M.I.): A.K.A.: Date of Birth: Mailing Address: /
More informationPATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY
PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY Please indicate whether you feel Living Hope Eating Disorder Treatment Center provided either Satisfactory or Unsatisfactory service for each number listed
More informationPOST-STROKE DEPRESSION
POST-STROKE DEPRESSION Stroke Annual Review March 7 th & 8 th, 2018 Justine Spencer, PhD, CPsych OVERVIEW What is Post-Stroke Depression (PSD)? Risk factors/predictors Impact of PSD Treatment and Management
More informationAnnual Wellness Visit
Chief Complaint/HPI: Annual Wellness Visit CAD Old MI PVD COPD CKD Renal Dialysis Diabetes CVA Late effect CVA DVT PE Seizure Chronic Hep B Chronic Hep C MEDICAL & SURGICAL HISTORY Please : (past conditions,
More informationProblem Summary. * 1. Name
Problem Summary This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question
More informationSupplementary Materials:
Supplementary Materials: Depression and risk of unintentional injury in rural communities a longitudinal analysis of the Australian Rural Mental Health Study (Inder at al.) Figure S1. Directed acyclic
More informationIf you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
More informationTo insure that your physical examination is of the highest quality and comfort, please observe the following:
Dear Patient: To insure that your physical examination is of the highest quality and comfort, please observe the following: PHYSICAL EXAM NOTES Please bring the Physical Exam forms completely filled out
More informationMedicare Health Risk Assessment/Questionnaire
Medicare Health Risk Assessment/Questionnaire (Welcome to Medicare and Wellness Visits) Please complete the questions below. Your responses will help you receive the best health care possible. Check the
More information*2927* For Office Use Only. BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H /08;12/13;10/15 (d:\forms\hosp\.ofm) Initial appointment: Smoker:
MR # NAME DOB *2927* BASSETT MEDICAL CENTER Cooperstown, NY 13326-1394 DATE BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H-2927 3/08;12/13;10/15 (d:\forms\hosp\.ofm) PLEASE PRINT CLEARLY NAME: DATE OF
More informationMedicare & Dual Options. 1. Every page of the EMR document must include: a. Member Name b. Patient Identifiers (i.e. Date of Birth) c.
Medicare & SUBMITTING PROGRESS NOTES OR EMR You may use your own progress notes or Electronic Medical Record (EMR) to document the annual comprehensive examination. The EMR must include the elements indicated
More informationWelcome to NHS Highland Pain Management Service
Welcome to NHS Highland Pain Management Service Information from this questionnaire helps us to understand your pain problem better. It is important that you read each question carefully and answer as
More informationMedical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
More informationThese questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad people feel.
ADAPTED PHQ-9 & GAD-7 QUESTIONNAIRES How to fill in these questionnaires: These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad
More informationPRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
UF Health Senior Care PO Box 100383 Gainesville, FL 32608 352-265-0615 Fax 352-294-5803 PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the
More informationJessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator
Alleviating Depression and Anxiety through Wellness Promotion Jessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator Public Health Approach Mental Health is a public
More informationMajor Depressive Disorder Wellness Workbook
Framing Major Depressive Disorder Major Depressive Disorder Wellness Workbook This Workbook belongs to you and you decide how to use it. You decide who to show it to and whether or not you want someone
More informationWhy Do I need an Annual Wellness Visit?
Why Do I need an Annual Wellness Visit? To Our Medicare Patients: Medicare covers once a year wellness exam. There is no deductible, copay or coinsurance with your wellness visit. Medicare is very specific
More informationMEDICARE ANNUAL WELLNESS VISIT
www.southbendclinic.com Granger Family Med. 52500 Fir Road Granger, IN 46530 574-271-0700 Ironwood Rd. 2102 E. Inwood South Bend, IN 46614 574-299-2400 South Bend Clinic Main 211 Eddy St. South Bend, IN
More informationINSTRUCTION MANUAL Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures
PHQ and GAD-7 Instructions P. 1/9 INSTRUCTION MANUAL Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures TOPIC PAGES Background 1 Coding and Scoring 2, 4, 5 Versions 3 Use as Severity
More informationPrevalence of depression among patients with suspected tuberculosis at the Health Center of Duque de Caxias, Rio de Janeiro, Brazil
Prevalence of depression among patients with suspected tuberculosis at the Health Center of Duque de Caxias, Rio de Janeiro, Brazil Karina Marcia de Castro Silva Afrânio Kritski, Anna Cristina Calçada
More informationPriority Care Program
Priority Care Program A GUIDE FOR YOUR HEALTH, WELLNESS AND SAFETY AFTER HOURS CARE holidays, weekends, nights 1. IF YOU ARE HAVING AN EMERGENCY, CALL 911 IMMEDIATELY. 2. If your issue is not an emergency
More informationMental Health measures workgroup Update. 14 th Washington Group meeting Buenos Aires 8-10 October 2014
Mental Health measures workgroup Update 14 th Washington Group meeting Buenos Aires 8-10 October 2014 Overview Discussion document revised Key considerations Review of most commonly used instruments Proposal
More informationChristina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
More informationINSOMNIA SEVERITY INDEX
Name: Date: INSOMNIA SEVERITY INDEX For each of the items below, please circle the number that most closely corresponds to how you feel. 1. Please rate the CURRENT (i.e. last 2 weeks) severity of your
More informationChronic Condition Toolbook: Major Depressive Disorder. Focusing on Depression and Its Symptoms
Chronic Condition Toolbook: Major Depressive Disorder Focusing on Depression and Its Symptoms Table of Contents Focusing on Major Depressive Disorder... 1 Major Depressive Disorder Algorithm... 2 The Importance
More informationConscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND 58078 (701) 478-7199 INTAKE FORM BIRTH DATE: / / Age: Email: YOUR NAME FIRST: MIDDLE INITIAL: LAST: YOUR ADDRESS COMPLETE
More informationWestminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
Westminster IAPT Primary Care Psychology Service Opt-In Questionnaire In order to get a better idea of your difficulties, we would be grateful if you could complete the attached registration form and questionnaire.
More informationMU - Selection & Configuration of Measures
MU - Selection & Configuration of Measures Presenter: Christy Erickson October 14, 2011 Objectives Review the 15 Core Measures and highlight some findings from the field Discuss the MU Menu and Clinical
More informationPeer Support / Social Activities Overview and Application Form
Peer Support / Social Activities Overview and Application Form What is Peer Support? Peer support is when people use their own experiences to help each other. What happens during peer support sessions
More informationADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
More informationClinic Adult Patient Demographics
Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
More informationObjectives. Background and Significance. Background and Significance. Depression Screening: QIP in an Infectious Disease Primary Care Practice
Depression Screening: QIP in an Infectious Disease Primary Care Practice Karen Holen Lyda MS NP Paul F. Cook PhD Steven C. Johnson MD Objectives Describe relevance of identifying depression in a clinic
More informationLifeBridge Physician Network Care Path Depression, Substance Abuse June 26, 2015
LifeBridge Physician Network Care Path Depression, Substance Abuse June 26, 2015 LBPN Care Path Aim: To develop and implement standard protocols, based on the best evidence, that provide a consistent clinical
More informationSleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
More informationLambeth Psychological Therapies
Complaints procedure: If you are not happy about your experience with our service, you can speak to a member of staff directly; alternatively, you can contact the PALS Office. To make a formal complaint,
More informationIf you have any difficulties in filling out the forms, please contact our team administrator on
Westminster IAPT Primary Care Psychology Service Lisson Grove Health Centre Gateforth Street London NW8 8EG Team Administrator Tel: 07971315596 Dear Sir/Madam Thank you for requesting this opt-in pack
More informationMEASURING CARE QUALITY
MEASURING CARE QUALITY Region December 2013 For Clinical Effectiveness of Care Measures of Performance From: Healthcare Effectiveness Data and Information Set (HEDIS ) HEDIS is a set of standardized performance
More informationMedicare Preventive Visit Form Office: Use this form if not using EPIC. Patient Name:
Medicare Preventive Visit Form Office: Use this form if not using EPIC G0402 IPPE G0438 AWV G0439 - subsequent REQUIRED EXAM Patient Name: DETAILS (Include description of all abnormal Body Mass Index Ht.
More informationClinical Practice Guideline: Management of Major Depression in Primary Care
Clinical Practice Guideline: Management of Major Depression in Primary Care Approved, CHP Quality Improvement Committee 3/27/01, 10/22/02, 10/28/03, 11/2/04, 11/1/05, 9/8/09, 5/10/11, 5/14/13, 5/12/15,
More informationDepression Assessment and Management. John Kern MD Clinical Professor University of Washington
Depression Assessment and Management John Kern MD Clinical Professor University of Washington Handouts Antidepressant Treatment Flowchart Managing antidepressant nonresponse handouts 2 Diagnosis PHQ-9
More informationHumana Practitioner Assessment Form
Humana Practitioner Assessment Form Please fill in the information requested in this box only. Your physician will complete the remaining sections of this assessment. Patient name: Date of service: Humana
More informationMedicare Well Patient Visits
Last First MI Type of Wellness Exam: Medicare Part B Eligibility Date: Vital signs: IPPE Welcome to Medicare Select G0402, G0403, G0404 or G0405 (1 time during first 12 months on Medicare) Medicare Well
More informationPractitioner Assessment Form (PAF)
Practitioner Assessment Form (PAF) What is the PAF? The practitioner assessment form is a health assessment designed to assist the physician in collecting specific information on Medicare Advantage patients.
More informationTotal Health Quality Indicators For Providers 2018
Well Adult Well Visit 20 yrs > Yearly 99385-87, 99395-97, G0402, G0438, G0439, G0463 Total Health Quality Indicators For Providers 2018 Adult- Preventive Z00.00 Report ALL components of an annual visit
More informationMedicare Health Information Questionnaire
Initial Preventive Physical Examination - IPPE (Welcome to Medicare Preventive Visit) Annual Well Visit (Annual Wellness Visit) Subsequent Annual Well Visit - SAWV Patients Story: Married Widowed Divorced
More informationMeasurement of Psychopathology in Populations. William W. Eaton, PhD Johns Hopkins University
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this
More informationQUALITY IMPROVEMENT Section 9
Quality Improvement Program The Plan s Quality Improvement Program serves to improve the health of its members through emphasis on health maintenance, education, diagnostic testing and treatment. The Quality
More informationWellness Visit Assessment
Today s Date: Wellness Visit Assessment DOB: Gender: Male Female Patient Name: Welcome to your annual wellness visit! Thank you for choosing Saint Mary s Medical Group. We look forward to providing the
More informationProvider Perspective of Quality Measurement
Provider Perspective of Quality Measurement The American Medical Group Association supports its members in enhancing population health and care for patients through integrated systems of care Improve
More informationTotal Health Quality Indicators For Providers 2017
Well Adult Well Visit 20 yrs > Yearly 99385-87, 99395-97, G0402, G0438, G0439, G0463 Total Health Quality Indicators For Providers 2017 Adult- Preventive Z00.00 Report ALL components of an annual visit
More informationSAN DIEGO SEXUAL MEDICINE
SAN DIEGO SEXUAL MEDICINE INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF) These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try
More informationHelp is at hand. Lambeth. Problems at work? Depressed? Stressed? Phobias? Anxious? Can t find work? Lambeth Psychological Therapies
South London and Maudsley NHS Foundation Trust Problems at work? Lambeth Stressed? Depressed? Anxious? Phobias? Can t find work? Lambeth Psychological Therapies 020 3228 6747 Help is at hand Page 1 Are
More informationPrimary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
More informationAdult HEDIS & STARs Measures
HEDIS AND MEDICARE STAR DOCUMENTATION & CODING GUIDE Adult HEDIS & STARs Measures Adult BMI Assessment (ABA) 18 74-year-old Antidepressant Medication Management (AMM) Breast Cancer Screening (BCS) Cervical
More informationHistory Form for Exceptional Home-Based Care
Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible
More informationName of Client: Former or Maiden name: Date of Birth: Age: SSN# Gender: Male Female
Adult Intake Forms LAKE COUNTRY ASSOCIATES, INC. 515 Bridge Street East, Park Rapids, MN 56470 ph: 218-366-9229 1426 Bemidji Ave NW, Ste 1 Bemidji, MN 56601 ph: 218-444-2233 Fax: 218-237-2520 11 Main Street
More informationDepression Symptoms of Depression Treatment of Depression
Depression Depression Major depressive disorder or clinical depression is a common but serious mood disorder. It can cause severe symptoms that affect how you feel, think, and handle daily activities,
More informationBlue Precision HMO Annual Health Assessment Form - Adult
BCBSIL Subscriber ID: Name of Physician: Blue Precision HMO Annual Health Assessment Form - Adult Reason(s) for Visit: Date of Service: Medications: Name of Medication Dosage Frequency Comments Allergies:
More informationWelcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
More informationPatient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
More informationMEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE
PATIENT NAME: Date of Birth: MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE Today s Date: The Annual Wellness Visit is for preventative health and provided by Medicare. This is not a visit to evaluate new
More informationPlaying the Game: Strategies For Completing the ACO Measures
ACO Quality Scoring Playing the Game: Strategies For Completing the ACO Measures June 2, 2016 1 2 Quality Measure Score Primary Focus on: GPRO (Group Practice Reporting Option) Measures >50% Preventative
More informationHORMONE BALANCE QUESTIONNAIRE FOR MEN
HORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal
More informationNew Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
More informationRoy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department
Roy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department That weight gaining diet I put you on is really working! This won t hurt me a bit. You re in good shape for the
More informationSPIRIT CMTS Registry Example Patient for Care Manager Training
SPIRIT CMTS Registry Example Patient for Care Manager Training Getting Started The following scenario is designed to help you learn how to use the Care Management Tracking System (CMTS) registry to facilitate
More informationBehavioral Risk Factor Surveillance Survey
Licking County Health Department Community Health Assessment Data Behavioral Risk Factor Surveillance Survey 28 A key strategic objective of the Licking County Health Department is to Monitor health status
More informationNaresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX Phone: (817) Fax: (817)
Naresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX 76104 Phone: (817) 877-8885 Fax: (817)332-9093 Patient's Name: DOB: Date: Email: What is the reason for your visit?
More informationPulse: Wt: pressure) Cancer; type: convulsionss. Dementia Suicidal ideation Bipolar disorder. Relationship
VITAL SIGNS: BP: Pulse: Temp: Resp.: Ht: Wt: BMI: ALLERGIES (medicines, other): MEDICAL HISTORY: Does patient have/havee history of any of the following (check all that apply)? Amputation; site: Hypertension
More informationWelcome to our practice! Please take a few moments to complete the following information.
Today s Date: Welcome to our practice! Please take a few moments to complete the following information. Personal Background Full Gender: Male Female Transgender Age: Race: White Black/African American
More informationDate of Birth (mm/dd/year): 2. How much would you like to weigh (desired weight)?
MFA Weight Management Practice Initial Consultation Survey Name: Date of Birth (mm/dd/year): I. Weight History 1. What is the main reason you want to lose weight? _ 2. How much would you like to weigh
More informationHow this Framework can help you:
How this Framework can help you: This framework is designed to provide a standard set of strategies and tools specific to help you improve care provided in the ambulatory environment. The framework has
More informationPatient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:
Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn
More informationMedical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
More informationMEASURING CARE QUALITY
MEASURING CARE QUALITY Region November 2016 For Clinical Effectiveness of Care Measures of Performance From: Healthcare Effectiveness Data and Information Set (HEDIS ) HEDIS is a set of standardized performance
More informationDear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
More informationThis product was developed by the RWJ Diabetes Self Management Program at Community Health Center, Inc. in Middleton, CT. Support for this product
This product was developed by the RWJ Diabetes Self Management Program at Community Health Center, Inc. in Middleton, CT. Support for this product was provided by a grant from the Robert Wood Johnson Foundation
More informationEPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
More information