Annual Physical, Pediatric Wellness, and Medicare Visits Consent Form - Information and Financial Consent

Sep 17, 2026

Information and Consent form from NYU Langone Health Faculty Group Practice for patients completing an Annual Physical Examination, Pediatric Wellness visit, and Medicare-related preventive visits. It explains eligibility timing, what each visit includes, and key scenarios that may trigger out-of-pocket costs, such as required PCP selection rules, limits on office services per day, non-preventive tests, and additional concerns addressed during the visit. It also details Medicare IPPE and AWV coverage, including cost expectations and signature-based acknowledgement of proceeding with care under financial consent.

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Annual Physical Examination and Pediatric Wellness Visit

Medicare and Medicare HMO Patients

Acknowledgement and Financial Consent

NYU Langone Health Faculty Group Practice Information and Consent about Annual Physical, Pediatric Wellness, and Medicare Visits | Patient Information
Last Name:
MRN \#: | First Name:
Date of Birth: | | --- | --- | | Annual Physical Examination and Pediatric Wellness Visit
• What is it? An annual physical, also known as a well visit, is a check-up to review your current health and medical history.
• When are you eligible? Most plans cover one visit per calendar year.
• Will there be out-of-pocket costs? Some common restrictions could result in out-of-pocket costs:
o If your insurance carrier requires a PCP selection and you have this service with another provider whois not your PCP.
o If your carrier covers only one office service per day
o If your provider performs tests or services during the visit that aren’t covered under the preventive benefit, such as vaccinations, lab work, or EKGs.
o If you discuss any additional medical concerns during your visit, your provider may need to bill for both the annual physical examination and the evaluation and treatment of those concerns.
􀂃 This could result in a co‑payment for the evaluation and management portion of the visit, even if the appointment was originally scheduled as a preventive visit. | | | Medicare and Medicare HMO Patients
Welcome to Medicare Visit (Initial Preventive Physical Exam or IPPE)
• What is it? A one-time preventive visit to review your health history, learn about preventive services, and create a personalized care plan. This is not a physical exam.
• Who is eligible? New Medicare Part B (Outpatient and physician services coverage) patients.
• How often? One time within the first 12 months of Medicare Part B enrollment
• Will there be out-of-pocket costs? No, you owe $0 if your provider accepts Medicare.
Annual Wellness Visit (AWV)
• What is it? A yearly visit with your doctor to create or update your personalized prevention plan. This is not a physical exam.
• Who is eligible? Medicare patients with Part B for more than 12 months.
• How often? Every 12 months after your Welcome to Medicare Visit or last AWV.
• Will there be out-of-pocket costs? You may have to pay coinsurance, and your Part B deductible could apply if your provider performs tests or services during the visit that aren’t covered under the preventive benefit.
􀂙 Medicare does not cover routine physical exams | | Acknowledgement and Financial Consent I wish to proceed with the visit and understand that my benefit plan may not cover all services provided to me. I have read and understand the above. Patient Signature Date

FAQs

What is an annual physical (well visit) and what information is reviewed?

An annual physical, also called a well visit, is a check-up to review current health and medical history.

When are most patients eligible for an annual physical visit, and can out-of-pocket costs apply?

Most plans cover one visit per calendar year. Out-of-pocket costs may result when insurance rules, service limits, or non-preventive tests/services occur, or when additional concerns are billed separately.

What is the Medicare Welcome to Medicare Visit (IPPE), and who is it for?

It is a one-time preventive visit for new Medicare Part B patients to review health history, learn preventive services, and create a personalized care plan, and it is not a physical exam.

Sep 17, 2026

Uploaded by Ethan Miller