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Physical Exam Consent

Carefree Internal Medicine, PC

Seema Mohan M.D. & Diane Hrdina, M.D.

NOTICE TO PATIENTS REGARDING ANNUAL WELLNESS VISIT/ PHYSICAL EXAM

When having an Annual Wellness Visit/Complete Physical Exam your insurance carrier defines this as a preventative care visit. Due to the national coding laws, we must bill this visit as a preventative care visit. If during this visit you have additional concerns, chronic conditions or new conditions that require diagnosis, counseling and/ or treatment, you may incur additional office or lab charges. These visits will be sent to your insurance along with the preventative care visit. If your insurance for any reason does not cover some or all of the charges then it will become the patients responsibility to cover the cost. Please do not ask us to rebill by changing a procedure or diagnostic code.

Annual Wellness Visit/ Complete Physical Exam include the following, unless otherwise specified:

  • Complete history and medication review
  • Chemistry Panel
  • Lipid Panel ( If indicated )
  • Complete blood count (CBC)
  • Thyroid Screen
  • PSA (men ages 50-75)
  • Stool Occult Blood (men and women over age of 50, if indicated)
  • EKG ( If indicated )
  • Breast Exam, Pelvic Exam and Pap smear ( If indicated )
  • Digital Rectal Exam ( If indicated )
  • Mammogram ( If indicated )
  • Colonoscopy –Recommended
  • Update Vaccines

I have read and understand the statements above. I agree to pay all non-covered services provided at visit today.

Patient's Name:

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