Visit purpose Routine follow-up or medication question Wellness, prevention, or screening discussion Mental health or counseling visit Therapy, rehab, or chronic condition support New or urgent change that may need in-person care
Coverage context Original Medicare Medicare Advantage plan Medicare plus Medicaid or other help VA, employer, retiree, or other coverage Not sure
Appointment status Not scheduled yet Telehealth visit is scheduled Past or current technology problem Recent virtual visit needs follow-up Not sure
Technology access Video device and internet are ready Phone only may be needed Device, link, portal, or app needs testing No reliable device, internet, or private space Not sure
Communication support No special support expected Hearing, vision, captioning, or screen support Interpreter or language support Memory, anxiety, or note-taking support Mobility, fatigue, or positioning support
Caregiver role Older adult will attend alone Helper will be in the room Helper needs to join remotely Facility, agency, or building staff may help Not sure
Privacy and permission setup Privacy and permissions seem ready Caregiver release or proxy access may be needed Password sharing or portal access is unclear A private space is hard to arrange Not reviewed yet
After-visit follow-up need Simple notes and next appointment Medication, pharmacy, or refill follow-up Tests, referrals, images, or lab follow-up Equipment, home health, or therapy follow-up Bill, copay, denial, or coverage question
In-person backup plan In-person backup is clear Transportation would need planning Concern may need hands-on exam or testing No backup plan yet Not sure
Local help need No local help needed Help with device, internet, or portal Backup transportation or escort help Coverage, cost, or plan help Caregiver support or local aging services
Use this as a telehealth setup and follow-up planner.
Use broad planning answers only. Do not enter names, addresses, birth dates, diagnoses, Medicare numbers, Social Security numbers, account numbers, passwords, medicine names, portal details, or private medical facts into this worksheet.
This planner is educational and organizational only. It is not medical, legal, insurance, benefits, technology, financial, privacy, or emergency-response advice. Confirm personal symptoms, coverage, costs, technology requirements, caregiver access, and urgent concerns with qualified clinicians, the health plan, SHIP, or local support.
Official references:
Medicare telehealth coverage ,
MedlinePlus telehealth overview ,
NIA telehealth tips for older adults ,
Eldercare Locator .
