Medicare Annual Wellness Visit Appointment Request

Medicare Annual Wellness Visit Appointment Request
First Name*
Last Name*
You must be 65 years or older to receive medicare benefits. Please schedule a primary care appointment through easyschedule if you are not 65 or older.
Date of Birth*

MonthDayYear
Date
Phone Number Type*

CellHome
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Do you use Follow My Health Patient Portal?

YesNo
Is your Primary Care Provider with Baptist Medical Group?*

YesNo
You answered no. Would you like to establish care with a Baptist Medical Group Primary Care Provider?*

YesNo
Which Medicare plan do you have?
What year did your Medicare first become in effect? (only need year)
Please select from the following:
I prefer

In office visitTelehealth visit
Thank you for choosing Baptist Medical Group. We request that you reach out to your primary care provider.
Should be Empty:

Thank you for choosing Baptist Medical Group. We request that you reach out to your primary care provider.