The Medicare Annual Wellness Visit has a fixed list of required elements, and a visit that misses one does not get paid. This two-page template walks the whole list: which AWV is being billed and whether a prior G0438 is on record, the health risk assessment, medical and family history, current providers and suppliers, a medication reconciliation, measurements, and the required screenings for depression, cognition, and functional ability and safety. Page two carries the personalized prevention plan, an advance care planning block for +99497, and the attestation.

The screening rows ask for the tool used and the score, not just a conclusion, because "screened, negative" is what auditors reject. The page also prints the three ways an AWV gets denied: sequence, since G0438 is once per lifetime and must precede G0439; timing, since neither can be billed within 365 days of the G0402 initial preventive physical exam; and missing elements, since the health risk assessment and the written prevention plan furnished to the patient are both mandatory. An AWV is also not a routine head-to-toe physical, which Medicare does not cover. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.