| Medicare: Initial Preventive Physical Examination--Consent
Form
The Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 provides for coverage under Medicare Part B of an
initial preventive physical examination (IPPE), including a screening electrocardiogram
(EKG) for new beneficiaries (subject to certain eligibility and other limitations)
effective for services furnished on or after January 1, 2005. To be eligible for this service a patient must:
1)
A new beneficiary on or after January1, 2005.
2)
Present their Medicare Eligibility card
3)
Receive the service within 6 months of their Medicare eligibility
date.
Payment for Service:
The IPPE is a billable service to Medicare and subject to all applicable
deductibles and co-insurance. Since this
is likely to be the first Medicare service for many patients, it is likely that
the patient will pay out of pocket as part of their deductible.
The Medicare deductible in 2005 is $110.
The charge for the IPPE is $94.57 for the examination and $25.91 for the
EKG and interpretation. Any screening blood
work or other testing done as follow up or in conjunction with the IPPE is billed
separately. Services Included in the Initial Examination:
1)
Review of your medical and social history.
2)
Review of your potential (risk factors) for depression.
3)
Review of your functional ability and level of safety.
4)
An examination to include measurement of height, weight,
blood pressure, visual acuity, and other factors deemed appropriate by the physician
based on your medical and social history.
5)
Performance and interpretation of an EKG.
6)
Education, counseling, and referral as deemed appropriate
by the physician based on the results of the review and evaluation as described
above.
7)
A brief written plan, education, or counseling for obtaining
the appropriate screening and preventive services covered separately under Medicare
Part B.
What to Expect:
1)
An extensive questionnaire and screening form which you
will need to fill out before your visit to review your medical history, risk factors
for depression, and your functional level of safety.
2)
A meeting and examination with the physician to review
pertinent information from the questionnaire, a measurement of height, weight,
blood pressure, visual acuity, and other factors directly related to the questionnaires.
3)
An EKG and its interpretation.
4)
Any screening or preventives services for which you qualify
and can be provided in the office today.
What to Expect in the Form of a Plan:
During
your visit the doctor will explain what preventive services you should obtain
based on the questionnaires you filled out and the results of any examination.
We will arrange for or provide you the appropriate locations to obtain
other preventive services for which you are eligible.
What Not to Expect:
The IPPE is intended to
provide the patient and the doctor with a framework for obtaining preventive services
covered by Medicare Part B. This visit is not intended for the detailed
evaluation of acute or chronic problems. Problems
of these types may be briefly addressed today, but a more likely scenario is that
the physician will ask you to return on another day to address specific acute
or chronic problems.
Consent:
I have read and understand
the above document and agree to pay for any services not covered by Medicare either
because my deductible applies or I am otherwise ineligible for this service. Name (Please Print): ________________________________________
Date: _____________________ Signature: ___________________________________________________________________________ | 
