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AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMSThe Arizona Health Care Cost Containment System (AHCCCS) EPSDT Tracking Forms shall be used by all providersoffering care to AHCCCS members under 21 years of age to document age-specific, required information related toEPSDT screenings and visits. Only AHCCCS EPSDT Tracking Forms may be used; paper form substitutes are notacceptable. However, providers may choose to utilize an electronic EPSDT Tracking Form generated through AHCCCS(once available) or the provider’s electronic health record system, so long as the electronic form includes all componentspresent on the AHCCCS EPSDT Tracking Form. These components include, but are not limited to:1. Documentation of comprehensive physical exam (including appropriate weights and vital signs)2. Age-appropriate screenings (vision, hearing, oral health, nutrition, developmental, nutritional, tuberculosis (TB)and lead)3. Developmental surveillance4. Anticipatory guidance (Age Appropriate Education and Guidance)5. Social-emotional health (Behavioral Health) surveillance6. Age-appropriate labs and immunizations, and7. Medically necessary referrals including those to the member’s dental home starting at 1 year of age, or sooner asneeded, for routine biannual examinations.Refer to AMPM Chapter 400 for EPSDT responsibilities and services.Contractors are required to print two-part carbonless EPSDT Tracking Forms (a copy for the member’s medicalrecord and a copy for providers to send to the Contractor’s MCH/EPSDT Coordinator) and distribute these forms totheir contracted providers. Providers may also choose to print the EPSDT Tracking Form from the AHCCCS website.A copy of the completed EPSDT Tracking Form(s), signed by the clinician, should be placed in the member's medicalrecord. Depending on the member’s enrollment status, an additional distributed copy of the EPSDT Tracking Formmay be required, as detailed below:1. For members enrolled with a Contractor: A copy of the completed and signed form shall be sent to that Contractor.2. For AHCCCS Fee-For-Service members [e.g., enrolled in the American Indian Health Program (AIHP)]: Theprovider shall maintain a copy of the EPSDT Tracking Form in the member’s medical record, but does not need tosend a copy elsewhere.Contractors and providers may reproduce EPSDT Tracking Forms as needed. All others may reproduce the formswith permission of AHCCCS via an approved written request directed to:AHCCCSDivision of Health Care ManagementCQM/Maternal and Child Health 701 E.Jefferson, Mail Drop 6700Phoenix, AZ 85034(602) 417-4410NOTE: The Centers for Medicare and Medicaid Services require AHCCCS to provide specified services to ourEPSDT population. These EPSDT Tracking Forms have been designed to ensure that needed services areperformed, and that our members are provided an opportunity to receive preventive care. Do NOT alter oramend these forms in any way without discussion with our Maternal and Child Health Manager at the addressabove. Contact information for AHCCCS Contracted health care plans may be found at www.azahcccs.gov.430, Attachment E - Page 1 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMS3-5 DAYS OLD AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderAdmitted to NICU: (Birth) Yes NoAllergies:First NamePCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Current Medications/Vitamins/Herbal Supplements:Birth cmAgePulse:Resp:Head Circumference:%cm%Hospital Newborn Hearing Screen: ABR OAE: Rt. Ear Pass ReferLt. Ear Pass Refer UnknownSecond Newborn Hearing Screen (If 2ndNeeded/Completed): ABR OAE: Rt. Ear Pass Refer Lt. Ear Pass Refer UnknownFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?ORAL HEALTH: Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)NUTRITIONAL SCREENING: Breastfeeding Frequency/Duration:Supplements:Vit DFormula Type:Amount/Duration:Adequate Weight GainYes NoReceiving WIC ServicesDEVELOPMENTAL SURVEILLANCE: Rooting Reflex Startle Suck & SwallowANTICIPATORY GUIDANCE PROVIDED:Emergency/911Drowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing)Safe SleepShaken Baby PreventionPassive SmokeSafety at Home/Child-ProofingSun SafetyPacifier UseSupport Systems/ResourcesInfant Crying/Appropriate InterventionsOther:OtherGun SafetySafe Bathing/Water TemperatureBottle ProppingInfant BondingSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT):Positively to ChildCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)Skin/Hair/NailsEyes/Vision/Red SSMENT/PLAN/FOLLOW-UP:WNLFamily Adjustment/Parent RespondsAbnormal (see notes rological2nd Arizona Newborn Screening Bloodspot Test (5 – 10 Days of Age or First PCP Visit) OtherHepB (Not Previously Administered) OtherIMMUNIZATIONS DATE 1ST HEPB ADMINISTERED:ORDERED:Given at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedREFERRALS:ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral Other2nd Newborn Hearing Screen (If Needed)PROVIDER’SSIGNATURE:NPI: Date:LABS ORDERED:430, Attachment E - Page 2 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMS1 MONTH OLD - AHCCCS EPSDT TRACKING FORMDateLast NameFirst NamePrimary Care ProviderAdmitted to NICU: (Birth)YesNoAllergies:PCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Current Medications/Vitamins/Herbal Supplements:Birth cmAgePulse:Resp:Head Circumference:%cmHospital Newborn Hearing Screen: ABR OAE:Rt. Ear Pass ReferLt. ear Pass ReferUnknownSecond Newborn Hearing Screen (If 2nd Needed/Completed): ABR OAE: Rt. Ear Pass Refer Lt. Ear Pass Refer%UnknownFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?ORAL HEALTH: Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)NUTRITIONAL SCREENING: Breastfeeding Frequency/Duration:Supplements:Vit DFormula Type:Amount/Duration:Adequate Weight GainYes NoReceiving WIC ServicesDEVELOPMENTAL SURVEILLANCE:Responds to SoundsResponds to Parent’s VoiceFollows With Eyes to MidlineAwake For 1 Hour StretchesBeginning Tummy TimeOtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing)Safe SleepShaken Baby PreventionSafe Bathing/Water TemperaturePassive SmokeSafety at Home/Child-ProofingSun SafetyPacifier UseBottle ProppingInfant Bonding SOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT): Family Adjustment/Parent Responds Positively to ChildAppropriate Bonding/Responsive to Needs Postpartum DepressionCOMPREHENSIVE PHYSICAL EXAM:Infant Hands to Mouth/Self -CalmingWNLAbnormal (see notes below)Skin/Hair/NailsEyes/Vision/Red therAbnormal (see notes rologicalASSESSMENT/PLAN/FOLLOW-UP:2nd Arizona Newborn Screening Bloodspot Test (5 – 10 Days of Age or First PCP Visit) OtherResults of 2nd AZ Newborn Screening Received (If No, What Follow Up Taken:/HepB (Not Previously Administered)OtherIMMUNIZATIONS DATE 1ST HEPB/2ND HEPB ADMINISTERED:ORDERED:Given at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedREFERRALS:ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral Other2nd Newborn Hearing Screen (If Needed)PROVIDER’SSIGNATURE:NPI: Date:LABS ORDERED:430, Attachment E - Page 3 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary)
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMS2 MONTHS OLD -AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderAdmitted to NICU: (Birth)YesNoAllergies:First NamePCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Current Medications/Vitamins/Herbal Supplements:Birth Weight:lb ozRisk Indicators of Hearing Loss: Yes NoHospital Newborn Hearing Screen: ABR OAE:Rt. Ear PassSecond Newborn Hearing Screen (If 2nd Needed/Completed): Lt. Ear Pass ReferOAE: Rt. Ear Pass Refer Lt. EarAgePulse:Resp:Head Circumference:cm%UnknownPass ReferUnknownFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?ORAL HEALTH: Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)NUTRITIONAL SCREENING: Breastfeeding Frequency/Duration:Supplements:Vit DFormula Type:Amount/Duration:Adequate Weight GainYes NoReceiving WIC ServicesDEVELOPMENTAL SURVEILLANCE: Some Head Control Tummy Time/Lifts Head, Neck With Forearm Support Social SmileCoosBegins Imitation of Movement and Facial ExpressionsMakes Eye ContactFixes/Follows With Eyes to MidlineStartles At Loud NoisesOtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing)Safe Sleep Shaken Baby Prevention Safe Bathing/Water Temperature Passive SmokeSafety at Home/Child-Proofing Sun Safety Pacifier Use Bottle Propping Infant BondingSupport Systems/ResourcesInfant Crying/Appropriate Interventions Parent Reads to ChildOtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT): Family Adjustment/Parent Responds Positively to ChildAppropriate Bonding/Responsive to Needs Infant Hands to Mouth/Self-CalmingEnjoys Interacting With OthersPostpartum Depression OtherCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes below)Skin/Hair/NailsLungsEyes/Vision/Red MENT/PLAN/FOLLOW-UP:2nd Arizona Newborn Screening Bloodspot Test (If Needed) OtherResults of 2nd AZ Newborn Screening Received (If No, What Follow Up ORDERED:Given at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedREFERRALS:ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WIC Specialist:Developmental Behavioral OtherPROVIDER’SSIGNATURE:NPI: Date:LABS ORDERED:430, Attachment E - Page 4 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary)
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMS4 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderAdmitted to NICU: (Birth)YesNoAllergies:First NamePCP ph. #AHCCCS ID #Health PlanCurrent Medications/Vitamins/Herbal Supplements:Birth Weight:lbozDOBAccompanied By (Name)Risk Indicators of Hearing Loss:YesWeight:lb ozAgeRelationshipTemp:Pulse:Resp:No%Length:cm%Head Circumference:cm%FAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?ORAL HEALTH: Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)NUTRITIONAL SCREENING: Breastfeeding Frequency/Duration:Supplements:Vit DFormula Type:Amount/Duration:Adequate Weight GainYes NoReceiving WIC ServicesCereal Type:Plan to Introduce SolidsSoda/JuiceDEVELOPMENTAL SURVEILLANCE:Babbles and CoosLaughsBegins to Roll Front to BackPushes Up With ArmsControls Head WellReaches For ObjectsInterest in Mirror ImagesPushes Down With Legs When Feet on SurfaceAppropriate Eye ContactTummy TimeOtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing)Safe SleepShaken Baby PreventionSafe Bathing/Water TemperaturePassive SmokeSafety at Home/Child-ProofingSun SafetyBottle ProppingSupport Systems/ResourcesInfant Crying/Appropriate InterventionsDiscuss Child TemperamentEstablish Daily Routines/Infant RegulationEstablish Nighttime Sleep Routine/Sleep Through Night (Greater 5 hours) Parent Reads to Child OtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT):Family Adjustment/Parent Responds Positively to BabyInfant Hands to Mouth/Self-CalmingSmiles When Hears Parents’ VoicesAppropriate Bonding/Responsive to NeedsEasily Distracted/Excited by Discovery of Outside World Postpartum DepressionOtherCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes LABS ven at Today’s VisitParent sOtherDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form Completed ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherNPI: Date:430, Attachment E - Page 5 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E –AHCCCS EPSDT TRACKING FORMS6 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderFirst NamePCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Admitted to NICU: (Birth) Current Medications/Vitamins/Herbal Supplements:YesNoAllergies:Birth Weight:lbozDOBRelationshipRisk Indicators of Hearing Loss:YesWeight:lbAgeTemp:Pulse:Resp:NoHead Circumference:Length:oz%cm%cm%FAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?ERBAL LEAD RISK ASSESSMENT: Child At RiskYes No (If Yes, Appropriate Action to Follow) Lives in High Risk Zip CodeYes NoORAL HEALTH: Parent Cleaning Baby’s Gums With Washcloth/Infant Toothbrush Fluoride Supplement Fluoride Varnish by PCPNUTRITIONAL SCREENING: Breastfeeding Frequency/Duration:Supplements:Vit DFormula Type:Amount/Duration:Adequate Weight GainYes NoReceiving WIC ServicesCereal Type:Plan to Introduce SolidsSoda/JuiceDEVELOPMENTAL SURVEILLANCE: Using A String of Vowels Rolls Over Transfers Small ObjectsVocal ImitationSits With SupportExplores With Hands and MouthPeek-a-Boo/Patty CakeOtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing) Safe Sleep Shaken Baby Prevention Passive Smoke Safety at Home/Child-ProofingSun SafetyRefrain From Jump Seat/WalkerSleep/Wake CycleIntroduce CupBegin Using High ChairWary of StrangersIntroduce Board BooksParent Reads to ChildOtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT):Family Adjustment/Parent Responds Positively to BabyAppropriate Bonding/Responsive to NeedsRecognizes Familiar PeopleDistinguishes Emotions by Tone of VoiceSelf-CalmingEnjoys Social PlayPostpartum DepressionOtherCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes :LABS SSIGNATURE:Blood Lead Testing (Child At Risk)Finger Stick (Result:)VenousOtherHepBDTaP Hib IPV PCV Influenza Rotavirus OtherGiven at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherNPI: Date:430, Attachment E - Page 6 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E – AHCCCS EPSDT TRACKINGFORMS9 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderAdmitted to NICU: (Birth)YesNoAllergies:First NamePCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Current Medications/Vitamins/Herbal Supplements:Risk Indicators of Hearing Loss:YesWeight:Birth oHead Circumference:Length:%cm%cm%FAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?DEVELOPMENTAL SCREENING TOOL COMPLETED:ASQPEDSVERBAL LEAD RISK ASSESSMENT: Child At Risk Yes No (If Yes, Appropriate Action to Follow) Lives in High Risk Zip Code Yes NoORAL HEALTH: White Spots on Teeth: Yes No Parent Cleaning Baby’s Gums With Infant ToothbrushFluoride SupplementFluoride Varnish by PCP (Once Every 6mo )NUTRITIONAL SCREENING: Breastfeeding Formula Amount:Supplements: Vit D Receiving WIC ServicesAdequate Weight Gain Yes No Plan to Introduce Table FoodsDrinks From CupSoda/JuiceDEVELOPMENTAL SURVEILLANCE: Sits Independently Pulls to Stand/Cruising Plays Peek-A-Boo Uses Words “Mama/Dada”Waves Bye-Bye Wary of Strangers Immature Pincer Repeats Sounds/Gestures for Attention Explores Environment OtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionChoking Prevention/Soft Texture Finger FoodsCar/Car Seat Safety (Rear-Facing)Safe SleepShaken Baby PreventionPassive Smoke Safety at Home/Child-Proofing Sun Safety Sleep/Wake Cycle TV Screen Time Exploration/LearningRedirection/Positive ParentingLanguage/Read to Child/Introduce Board BooksFollow Child’s Lead in PlayParent Communicates to Child “What Things Are” (Ball, Cat, Etc.) OtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT): Family Adjustment/Parent Responds Positively to ChildAppropriate Bonding/Responsive to Needs Self-Calming Growing Independence Shows Preference for Certain People/ToysCries When Primary Caregiver Leaves Postpartum Depression Other:COMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes :LABS SSIGNATURE:Blood Lead Testing (Child At Risk) Finger Stick (Result:) VenousHgb/HctOtherHepB DTaP Hib IPV PCV Influenza OtherGiven at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form Completed ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherNPI: Date:430, Attachment E - Page 7 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E – AHCCCS EPSDT TRACKING FORMS12 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderFirst NamePCP ph. #Health PlanAdmitted to NICU: (Birth) Current Medications/Vitamins/Herbal Supplements:YesNoAllergies:Birth Weight:lbozVision Screening:Corrected:YesAHCCCS ID #No AutomatedDeviceDOBAccompanied By (Name)RelationshipRisk Indicators of Hearing Loss:YesWeight:lb oz%Length:cmRight: Pass Left: PassReferReferAgeTemp:Pulse: Resp:Head Circumference:%cm%Both: PassReferUnable toPerformFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?BLOOD LEAD LEVEL REQUIRED(see below)ORAL HEALTH: White Spots on Teeth: Yes No Daily Brushing (Twice by Parent) Fluoride SupplementFirst Dental Appointment Completed ScheduledDental Home: Provider NameFluoride Varnish by PCP(Once Every 6mo)NUTRITIONAL SCREENING: Breastfeeding Whole Milk AmountMilk Intake/WeaningAdequate Weight Gain Solids:Soda Juice SupplementsDEVELOPMENTAL SURVEILLANCE: First Steps “Mama/Dada” Specific Uses Single Words Scribbles Precise Pincer GraspFollows Simple One Step Requests Looks for Hidden Objects Extends Arm/Leg for DressingPoints to ObjectsPlays: Hides Object/Pushes Ball Back and ForthOtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning PreventionCar/Car Seat Safety(Rear-Facing)Passive SmokeSafety at Home/Child-ProofingSun SafetyFollowing Child’s Lead in Play Ignore Tantrums/Give Attention to Positive Behaviors OtherChoking PreventionDiscipline/PraiseSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT):Family Adjustment/Parent Responds Positively to ChildSelf-Calming Prefers Primary Caregiver Over All Others Shy/Anxious With StrangersTantrums OtherCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes :LABS ORDERED:Blood Lead TestingTest (If at Risk) OtherIMMUNIZATIONSORDERED:HepA HepB MMR Varicella DTaP Hib IPV PCV InfluenzaHad Chicken PoxOtherGiven at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherREFERRALS:PROVIDER’SSIGNATURE:Finger StickVenous (Result )Hgb/Hct (Required, If not Done at 9 Months)NPI: Date:430, Attachment E - Page 8 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19ProprietaryTB Skin
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E – AHCCCS EPSDT TRACKING FORMS15 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NameFirst NameAHCCCS ID #Primary Care ProviderPCP ph. #Health PlanAdmitted to NICU: (Birth) Current Medications/Vitamins/Herbal Supplements:YesNoAllergies:Vision Screening:Corrected:YesNo AutomatedDeviceDOBAccompanied By (Name)RelationshipRisk Indicators of Hearing Loss:YesWeight:lb ozAgeTemp:Pulse:Resp:No%Length:cm%Right: Pass Left: PassReferReferHead Circumference:cm%Both: PassReferUnable toPerformFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about child? Do you feel safe in your home?VERBAL LEAD RISK ASSESSMENT: Child At Risk Yes No (If Yes, Appropriate Action to Follow)ORAL HEALTH: White Spots on Teeth: Yes NoDaily Brushing (Twice Daily by Parent)Fluoride SupplementFluoride Varnish by PCP (Once Every 6 Months) First Dental Appointment Completed Scheduled Dental Home Provider:NUTRITIONAL SCREENING: Feeds Self Breastfeeding Whole Milk Nutritionally Balanced Diet Junk Food Soda/JuiceSolids ActivitySupplementsOverweight Underweight Observation ReferralDEVELOPMENTAL SURVEILLANCE: Says 3-6 words Says No Wide Range of Emotions Repeats Words from ConversationUses Utensils Understands Simple Commands Climbs Stairs Walking Puts Objects In/Out of Container OtherANTICIPATORY GUIDANCE PROVIDED:Emergency /911Gun SafetyDrowning PreventionChoking PreventionCar/Car Seat Safety (Rear-Facing)Safety at Home/Child-Proofing Sun SafetyHelmet Use Growing IndependenceDefiant Behavior/Offer Child Choices Gentle Limit Setting/Redirection/Safety Reading/Parent Asks Child “What’s that?Follow Child’s Lead in Play Offer Opportunity to Scribble/Explore OtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT):Family Adjustment/Parent Responds Positively to ChildAppropriate Bonding/Responsive to Needs Self-Calming Frustration/Hitting/Biting/Impulse Control Communication/LanguageSocial Interaction/Eye Contact/Comforts Others Begins to Have Definite Preferences Other:COMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)WNLAbnormal (see notes below)Skin/Hair/NailsLungsEyes/Vision/Red MENT/PLAN/FOLLOW-UP:LABS ORDERED:Blood Lead Testing (Child At Risk/Not already Done at 12 Months)Finger Stick (Result:)VenousTB Skin Test (If at Risk) OtherIMMUNIZATIONSHepA HepB MMR Varicella DTaP Hib IPV PCV InfluenzaORDERED:Had chicken poxOtherGiven at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedREFERRALS:ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherPROVIDER’SSIGNATURE:NPI: Date:430, Attachment E - Page 9 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E – AHCCCS EPSDT TRACKING FORMS18 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderPCP ph. #First NameAHCCCS ID #Health PlanAccompanied By (Name)Admitted to NICU: (Birth) Current Medications/Vitamins/Herbal Supplements: Yes NoRisk Indicators of Hearing Loss: YesAllergies:Corrected:YesNo AutomatedDeviceozAgeRelationshipTemp:Pulse:Resp: NoWeight:lbVision Screening:DOBLength:%Right: Pass Left: PassReferRefercmHead Circumference:%Both: PassRefercm%Unable toPerformFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?DEVELOPMENTAL SCREENING TOOL COMPLETED:ASQMCHAT PEDSVERBAL LEAD RISK ASSESSMENT: Child At Risk Yes No (If Yes, Appropriate Action to Follow)ORAL HEALTH: White Spots on Teeth: Yes NoDaily Brushing (Twice Daily by Parent)Fluoride SupplementFluoride Varnish by PCP (Once Every 6 Months) First Dental Appointment Completed Scheduled Dental Home Provider:NUTRITIONAL SCREENING: Feeds Self Breastfeeding Whole Milk Nutritionally Balanced Diet Junk Food Soda/JuiceSolids Activity SupplementsOverweight Underweight Observation ReferralDEVELOPMENTAL SURVEILLANCE: Uses a cup Walks Says 10-20 Words Says “No” Name One Picture/2 ColorsFollows Simple Rules/Bring Me the Book Knows Animal Sounds OtherANTICIPATORY GUIDANCE PROVIDED:Emergency/911Gun SafetyDrowning preventionChoking PreventionCar/Car Seat Safety (Rear-Facing) Safety at Home/Child-ProofingSun Safety Helmet Use Never Leave Toddler AloneSibling InteractionDiscipline/LimitsGrowing IndependenceEncourage Expression of Wide Range of EmotionsRead to ChildOtherSOCIAL-EMOTIONAL HEALTH (OBSERVED BY CLINICIAN/PARENT REPORT): Family Adjustment/Parent Responds Positively to ChildAppropriate Bonding/Responsive to Needs Self-Calming Frustration/Hitting/Biting/Impulse Control Communication/LanguageDemonstrates Increasing Independence Defiant Behavior/Offer Child Choices OtherCOMPREHENSIVE PHYSICAL EXAM:WNL Abnormal (see notes below)Skin/Hair/NailsEyes/Vision/Red SSMENT/PLAN/FOLLOW-UP:WNLAbnormal (see notes rologicalLABS ORDERED:Blood Lead Testing (Child At Risk/Not already Done at 12 Months)Finger Stick (Result:)VenousTB Skin Test (If at Risk)OtherIMMUNIZATIONSHepA HepB MMR Varicella DTaP Hib IPV PCV InfluenzaORDERED: Had chicken pox OtherGiven at Today’s VisitParent RefusedDelayedDeferred Reason:Shot Record Updated Entered in ASIIS Importance of Immunizations Discussed Parent Refusal Form CompletedREFERRALS:ALTCS Audiology AzEIP CRS DDD Dental Early Head Start OT PT Speech WICSpecialist: Developmental Behavioral OtherPROVIDER’SSIGNATURE:NPI: Date:430, Attachment E - Page 10 of 19Effective Dates: 03/01/19, 05/07/19Approval Dates: 07/01/01, 06/01/03, 11/01/03, 01/01/04, 11/01/07, 10/01/09, 04/01/14, 10/18/18, 02/21/19Proprietary
AHCCCS MEDICAL POLICY MANUALPOLICY 430, ATTACHMENT E – AHCCCS EPSDT TRACKING FORMS24 MONTHS OLD - AHCCCS EPSDT TRACKING FORMDateLast NamePrimary Care ProviderFirst NamePCP ph. #AHCCCS ID #Health PlanAccompanied By (Name)Admitted to NICU: (Birth) Current Medications/Vitamins/Herbal Supplements:YesNoAllergies:Weight:lbVision Screening:Corrected:YesozNo AutomatedDeviceDOB%RelationshipRisk Indicators of Hearing Loss:Temp:NoHead Circumference:YesLength:cm%cmRight: Pass Left: PassReferReferAge%Both: PassReferPulse:Resp:BMI:kg/m2Unable toPerformFAMILY/SOCIAL HISTORY: (Current Concerns/ Follow-Up on Previously Identified Concerns)PARENTAL CONCERNS: How are you feeling about baby? Do you feel safe in your home?DEVELOPMENTAL SCREENING TOOL COMPLETED:ASQMCHATPEDSBLOOD LEAD LEVEL REQUIREDORAL HEALTH: White Spots on Teeth: Yes NoDaily Brushing (Twice Daily by Parent)Fluoride SupplementFirst Denta
The Arizona Health Care Cost Containment System (AHCCCS) EPSDT Tracking Forms be used by all providers shall . Phoenix, AZ 85034 (602) 417-4410 . NOTE: The Centers for Medicare and Medicaid Services require AHCCCS to provide specified services to our EPSDT population. These EPSDT Tracking Forms have been designed to ensure that needed .
