The Welcome to Medicare visit, or initial preventive physical examination, is a one-time visit in the first 12 months of Part B: history, a depression and safety review, a short exam with a vision check, and a written prevention plan. Copy the free template, with each element CMS lists for G0402 and the optional screening ECG. See two filled visits, how the IPPE differs from the AWV and a physical, and the 2026 rules.
For clinicians in the United States.
Blank welcome to Medicare visit template
FreeWELCOME TO MEDICARE VISIT: INITIAL PREVENTIVE PHYSICAL EXAMINATION Patient: [Name, date of birth] Visit date: [Date] Code: [G0402; add G0403, G0404, or G0405 if a screening ECG is done] ELIGIBILITY Part B start date: [Date; today is within the first 12 months: yes or no] Earlier IPPE: [None on the eligibility check, or the date found] Clinician: [Name; physician, physician assistant, nurse practitioner, or clinical nurse specialist] In the room: [Spouse, adult child, caregiver, interpreter, or nobody else] MEDICAL AND SOCIAL HISTORY Illnesses and treatments: [Past and current conditions, with the treatments tried] Operations, hospital stays, and injuries: [Each one, with the year] Allergies: [Drug, food, or other, and the reaction; or no known allergies] Medicines and supplements: [Every prescription and over-the-counter product, calcium, vitamins, and any other substance used, with dose and who prescribed it] Family history: [Conditions in relatives that may be inherited or raise this patient's risk, with ages] Tobacco: [Never, former, or current; pack-years; year quit] Alcohol: [Usual drinks per week and the most on one day] Other drugs: [Cannabis, illicit drugs, or misuse of prescriptions, or none] Diet: [Typical day of eating and drinking] Physical activity: [What, and minutes per week] Social engagement: [Work, volunteering, groups, family contact, or isolation] DEPRESSION RISK History: [Past or current depression or other mood disorder, or none] Screen: [Standardized tool and score, such as PHQ-2, with PHQ-9 if positive; not needed with a current depression diagnosis] Self-harm: [Asked directly if the screen is positive: answer] FUNCTION AND SAFETY Activities of daily living: [Bathing, dressing, eating, toileting, moving about: independent, or the help needed] Fall risk: [Falls in the past year, unsteadiness, fear of falling] Hearing: [Concerns, quick screen result, hearing aids] Home and community safety: [Stairs, smoke alarms, firearm storage, and driving when it applies] EXAM Height: [cm or in] Weight, BMI, and waist: [Weight; BMI; waist circumference if it fits better] Blood pressure: [Reading; repeat after rest if high] Visual acuity: [Chart used; each eye; with or without glasses] Balance and gait: [Observed walk, chair stand, or timed test, and the result] Other: [Any further check the history calls for, or none] END-OF-LIFE PLANNING Agreed to discuss: [Yes, or declined] Advance directive: [Has one, will prepare one, or not wanted; health care agent named] Your answer: [Whether you will follow the patient's directive, as told to them] OPIOID REVIEW AND SUBSTANCE USE SCREEN Current opioid prescriptions: [None, or each drug, dose, prescriber, and how long] Risk factors for opioid use disorder: [Found, or none] Pain and current plan: [Severity, effect on function, treatments in use] Non-opioid options: [What you discussed] Specialist referral: [Where, or not needed] Substance use risk factors: [Alcohol, drugs, family history, mental health, or none] Substance use tool: [Name and score, such as AUDIT-C, or questions only] Referral for treatment: [Where, or not needed] EDUCATION, COUNSELING, AND REFERRALS From today's findings: [Each finding, numbered, with the advice given or referral made] WRITTEN SCREENING AND PREVENTION PLAN Screening ECG: [Done today with the result, referred elsewhere, or not indicated and why] Screening tests: [Each test due, with the date of the last one and when the next is due] Vaccines: [Given today, due, or complete] Checklist given: [On paper, through the portal, or by mail] Separate problem care today: [None, or the problem, documented apart and billed with modifier 25] Next preventive visit: [First AWV, no sooner than 12 months from today] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care, IPPE, G0402, in person, with his wife; screening ECG, G0403
65-year-old man, new to the practice. Part B began September 1, 2026, the month he turned 65; today is 10 weeks in. No earlier IPPE on the eligibility check. Family physician, 40 minutes. His wife sat in at his request.
No diagnosed conditions. A pharmacy machine read his blood pressure as “a little high” last year; never followed up. Low back pain since lifting a pallet at 52, no surgery. Right inguinal hernia repair at 58; no hospital stays. No drug allergies. Medicines, from his bottles: hydrocodone-acetaminophen 5/325 mg, 1 tablet at bedtime most nights, from his previous doctor, who retired in June; ibuprofen 400 mg most mornings, bought over the counter; fish oil 1,000 mg. Family: father had a stroke at 68; mother had type 2 diabetes; younger brother had a heart attack at 59. No aneurysms that he knows of. Retired warehouse supervisor. Smoked a pack a day from 18 to 40, 22 pack-years; quit 25 years ago. Two beers on Friday and Saturday nights. No cannabis or other drugs. Fast-food lunch most days and 2 cans of regular soda. No exercise since he retired in March; mostly TV in the afternoon. Bowls in a league on Tuesdays and has his grandchildren every weekend.
No past depression or other mood disorder. PHQ-2 0, a negative screen.
Asked with the practice’s screening questions. Independent in every ADL. No falls; steady. Hearing: no concerns; repeated whispered words on both sides. Single-story house; smoke alarms tested in the spring. Two hunting rifles, unloaded, in a locked safe. Drives without trouble, day and night.
Height 178 cm (5 ft 10 in), weight 108 kg (238 lb), BMI 34.1, waist 114 cm (45 in). BP 156/96 left arm, seated; 150/94 after 5 minutes’ rest; 152/94 right arm. Pulse 76, regular. Visual acuity without glasses 20/25 in each eye. Normal gait; stood from the chair without using his arms. Other, from his history: no pulsatile mass felt in the abdomen, which doesn’t exclude an aneurysm at his size.
He agreed to talk about it. Has a will but no advance directive. Wants his wife as his health care agent and his daughter as the alternate. Given the state form and told how to complete it; told I will follow the wishes he writes down. He’ll bring a signed copy to the follow-up.
Hydrocodone-acetaminophen 5/325 mg at bedtime, about 25 tablets a month, for 2 years; last filled October 20. State prescription monitoring report: one prescriber, one pharmacy, no early fills. Opioid use disorder risk factors: none found; no past problems with alcohol or drugs in him or his family, no depression or anxiety, no benzodiazepines or sleep medicines. Pain 4 out of 10 at night, 2 in the day; it stops him walking more than 15 minutes. Non-opioid options: physical therapy for core strength, heat, and acetaminophen in place of daily ibuprofen, which can raise blood pressure. No specialist referral; prescribing to be reviewed at the follow-up. AUDIT-C 2; takes the hydrocodone only as prescribed. No treatment referral needed.
1, BP above 140/90 today with no diagnosis: home monitor, readings morning and evening for 7 days, log back in 2 weeks; daily ibuprofen stopped. 2, obesity, BMI 34.1: intensive behavioral therapy for obesity offered and accepted, first session at the follow-up; he chose water in place of soda and a 10-minute walk after dinner. 3, back pain on hydrocodone: physical therapy referral. 4, former smoker: one-time AAA screening ultrasound, below.
Checklist printed and sent to the portal. Screening ECG done today, G0403, after he heard it carries the usual deductible and coinsurance: sinus rhythm at 74, normal intervals, no left ventricular hypertrophy by voltage, no Q waves. Abdominal aortic aneurysm: one-time screening ultrasound ordered, as a man 65 to 75 who has smoked; no deductible or coinsurance. Colorectal: colonoscopy at 56 normal; next in 2027. Prostate: PSA benefits and harms discussed; he chose to be tested. Lung cancer screening: not eligible, quit more than 15 years ago. Labs: lipid panel, fasting glucose, and a one-time hepatitis C test. Vaccines: influenza and a pneumococcal conjugate vaccine today; recombinant zoster, 2 doses, and Tdap at his pharmacy. Separate problem care today: none. Follow-up in 2 weeks for the BP log, labs, and his first obesity session. First AWV: November 2027 or later.
Primary care, IPPE, G0402, in person, nurse practitioner; no ECG
66-year-old woman. Kept her employer coverage until she retired in March; Part B began April 1, 2026, 7 months ago. No earlier IPPE. She asked for a video visit because she cares for her husband at home; booked in person, since the IPPE isn’t on Medicare’s telehealth list. A neighbor stayed with her husband. Nurse practitioner, 45 minutes, alone with her.
Hypothyroidism for 12 years; TSH last checked 2 years ago. Osteoarthritis in both hands. Appendectomy at 30; one hospital stay, for pneumonia at 58. Allergy: penicillin, hives. Medicines: levothyroxine 75 mcg daily, ibuprofen 200 mg two or three times a week for her hands, vitamin D 1,000 units daily, and an over-the-counter diphenhydramine sleep aid most nights since July. Family: mother had glaucoma from 70 and broke a hip at 82; father had hypertension; sister well. Retired school bus dispatcher. Her husband has Parkinson’s disease, and she has been his main caregiver for a year. Never smoked. A glass of wine on Fridays. No cannabis or other drugs. Skips breakfast; often toast for dinner. Walked with a friend 3 mornings a week until the summer. Left her church choir in the spring; sees her son, who lives an hour away, about once a month.
No past depression. PHQ-2 4, positive, so the PHQ-9 followed: 14, moderate. Low mood and little interest most days for about 3 months; sleeps 4 to 5 hours; poor appetite. Asked directly about thoughts of death or self-harm: none. Feels “worn out and flat,” and guilty for resenting the caregiving.
Questionnaire completed in the waiting room, reviewed with her. Independent in every ADL. No falls or unsteadiness. Hearing: no concerns; repeated whispered words on both sides. Two-story house; she helps her husband on the stairs; smoke alarms working; no firearms. Driving: since the summer, headlights glare at night and road signs blur, so she avoids driving after dark.
Height 163 cm (5 ft 4 in), weight 58 kg (128 lb), BMI 21.8; down 4 kg since April. BP 124/78. Visual acuity with her distance glasses: right 20/50, left 20/30. Normal gait; stood from the chair without her arms; Timed Up and Go 9 seconds. Other: none.
She agreed. She is her husband’s health care agent but has no directive of her own. Wants to name her son. Given the state form; told I will follow her wishes as she writes them. She’ll fill it in with her son on his next visit.
No opioid prescriptions. AUDIT-C 1. No other drugs. Nightly diphenhydramine is a risk at her age: next-day drowsiness, confusion, and falls. No referral needed.
1, moderate depression with caregiver strain: counseling, medicine, or both discussed; she chose counseling first. Referral to the practice’s behavioral health clinician; caregiver support group and respite care through the Area Agency on Aging. TSH ordered, since an underactive thyroid can add to low mood. Told to call or text 988, or call 911, if she feels unsafe. Follow-up in 2 weeks with a repeat PHQ-9. 2, vision: ophthalmology referral for a dilated eye exam, for possible cataract and with her mother’s glaucoma; no night driving until seen. 3, sleep: stop the diphenhydramine; a fixed wake time and a short daylight walk. 4, weight loss: protein at breakfast; weight rechecked in 2 weeks.
Checklist printed and handed to her. Screening ECG: not indicated; no symptoms, normal blood pressure, and no cardiac risk factors. Mammogram: every 2 years; last one in May 2025, normal; next in May 2027. Colorectal: colonoscopy at 60 normal; next in 2030. Cervical screening: ended, after normal co-tests at 57 and 62. Bone density: DXA ordered; never done, and her mother broke a hip. Hepatitis C: tested in 2019, negative. Lipids normal in 2024. Vaccines: influenza and a pneumococcal conjugate vaccine today; recombinant zoster complete in 2023; Tdap in 2017, next tetanus dose in 2027. Separate problem care today: none. Follow-up in 2 weeks. First AWV: November 2027 or later.
The IPPE is set out in federal regulation, the Medicare Claims Processing Manual, and CMS guidance. These sources decide who qualifies, what the visit covers, and how it’s billed.
Proof the visit qualifies: the Part B start date, no earlier IPPE, and who did it. Medicare pays once per lifetime, so check before the patient arrives.
Avoid: Booking it in month 13. Once the first 12 months of Part B have passed, the first AWV is the visit to offer.
Illnesses, medicines, and family risks, then the habits that change risk: tobacco, alcohol, drugs, diet, activity, and social contact.
Avoid: Smoking history with no pack-years or quit date. Both decide whether the AAA ultrasound and lung cancer screening apply.
Past or current depression or other mood disorders, and a standardized screening tool for anyone without a current diagnosis.
Avoid: A positive PHQ-2 with nothing after it. Follow it with a fuller screen and a plan.
Four areas at least: activities of daily living, fall risk, hearing, and home safety. Ask screening questions, use a questionnaire, or observe.
Avoid: Leaving out driving. CMS counts it under community safety when it applies.
Short, and set by CMS: measurements, balance and gait, a vision screen, and anything more the history calls for. It isn’t a head-to-toe physical.
Avoid: Forgetting the vision screen. The IPPE requires it; the AWV doesn’t.
Offered, and done only if the patient agrees: how to prepare an advance directive, and whether you will follow it.
Avoid: “Discussed” and nothing more. Record the agent, the forms, and your answer about following the directive.
A four-part review for anyone with a current opioid prescription, and a substance use disorder screen for everyone, with referral when needed.
Avoid: Stopping at the drug name. Cover risk factors, pain and plan, other options, and referral.
Advice and referrals from today’s findings, then a short written plan, such as a checklist, for the screenings and preventive services the patient is due.
Avoid: Keeping the checklist inside the EHR. The written plan goes to the patient: print it, or send it to the portal.
The IPPE has to fall within 12 months of the Part B start date. Check the date when you book: past that window, Medicare won’t pay for it, and the first AWV is the visit to offer.
Many patients expect a full physical. Say what the visit covers when they book. If you examine or treat a problem, document it apart and bill it with modifier 25; their deductible and coinsurance apply to that part.
Visual acuity is a required IPPE measurement. Record the chart result for each eye and whether glasses were worn.
The once-in-a-lifetime screening ECG uses G0403, G0404, or G0405, not a 93000-series code. Tell the patient before it’s done that the visit’s cost-sharing waiver doesn’t cover it.
Vero Scribe writes the Welcome to Medicare note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your EHR or export it to Word or PDF. Vero works in 60+ languages.
Medical and social history, a depression risk review with a standardized tool, a review of daily activities, falls, hearing, and home safety, and a short exam: height, weight, BMI, blood pressure, balance, gait, and visual acuity. Then end-of-life planning if the patient agrees, an opioid review, a substance use screen, counseling and referrals, and a written checklist of screenings and preventive services. A once-in-a-lifetime screening ECG is optional. The template has a field for each.
The IPPE, G0402, happens once, in the first 12 months of Part B. The AWV, G0438 and then G0439, starts after that, at least 12 months after an IPPE, and repeats yearly. Only the IPPE requires a vision screen and offers the screening ECG; only the AWV requires a health risk assessment and a cognitive check. Patients don’t need an IPPE to get an AWV.
Not a routine physical. Its exam is short and set by CMS, and Medicare doesn’t cover a routine head-to-toe physical. If you examine or treat a problem at the same visit, document it as a separate service, with modifier 25; the deductible and coinsurance apply to that part.
Plan it in person. G0402 isn’t on Medicare’s 2026 list of telehealth services, and the code describes a face-to-face visit. The AWV codes, G0438 and G0439, are on the list.
Part B covers it when a physician, physician assistant, nurse practitioner, or clinical nurse specialist performs it. The AWV is wider: a nurse, health educator, or dietitian can do it under a physician’s direct supervision. Staff can still take measurements and collect history for you to review.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The Medicare AWV, G0438 and G0439: health risk assessment, cognition, screening schedule, risk factors, and the prevention plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
Screening, vaccines, and counselling due at an adult periodic health review, by age and sex, with a next due date on every line.
The first visits after arrival: interpreter, journey, IFHP coverage, catch-up vaccines, screening by region, mental health, and social needs.
Notes for Welcome to Medicare visits, follow-ups, and visits with several concerns.
Screening plans and prevention visits, drafted from the conversation.
The two-question depression screen, its cutoff of 3, and when to give the PHQ-9.
The full depression screen after a positive PHQ-2, with its severity bands.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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