A standardized Medicare wellness exam form is not required, though certain areas must be covered during the visit, according to the American Academy of Family Physicians. A health risk assessment form must be completed as part of the annual wellness visit, though the Centers for Medicare & Medicaid Services does not require a specific form be used.
The patient should fill out the health risk assessment before or during the visit, and the health care provider reviews the responses with the patient, advises Medical Economics. In addition to basic demographic data, the health risk assessment should ask the patient self-assessment questions about her health status, daily living activities, and psychosocial and behavioral health risks.
The health risk assessment completed for the Medicare annual wellness visit must be written at a sixth-grade literacy level and take most patients 20 minutes or less to fill out, notes the American Academy of Family Physicians. The answers on this form, in combination with the health care provider's observations and assessments during the visit, are used to develop an individualized preventive care plan for the patient.
Health care providers must document other elements required during an annual wellness visit for purposes of billing Medicare, notes Medical Economics. Additional areas to be covered in these visits include medical history, past and present providers, medications and an age-appropriate health screening schedule.