To take the questionnaire, please check the box next to the selection which best reflects how each statement applies to you. Be sure to choose the statement that applies to how you are feeling right now, not how you have felt in the past, or how you hope to feel in the future.
Please complete this checklist before seeing your doctor or nurse. Your responses will help you receive the best health and health care possible.
I authorize NMCROC to enact appeals on my behalf to my primary and secondary (if applicable) insurance carriers as it relates to denials for the following: in-office treatment, authorized injectable medications, claim denials, prescription medication and durable medical equipment. I understand that by allowing NMCROC to appeal denials on my behalf, I am not guaranteed a positive outcome.
The contents of this Medicare WellnessCheckup are derived from http://www.HowsYourHealth.org; Copyright ª 2012 the Trustees of Dartmouth College and FNX Corporation. Reprinted by permission. Physicians may duplicate for use in their own practices; all other rights reserved. http://www.aafp.org/FPM/20120300/Q11.IUNM
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