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10/13/2020PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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What is this visit for?

The visit is for an annual medical examination.

Who is required to file this visit for?

Individuals who are due for their annual medical examination.

How to fill out this visit for?

Complete the medical examination form provided by your healthcare provider.

What is the purpose of this visit for?

The purpose of this visit is to assess the overall health and detect any potential health issues.

What information must be reported on this visit for?

Personal information, medical history, current medications, and any symptoms experienced.

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