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Infant risk screening form - Mississippi Division of Medicaid - medicaid ms 2026
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How to use or fill out Infant risk screening form - Mississippi Division of Medicaid - medicaid ms
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the infant's name, date of birth, address, and Medicaid number in the designated fields.
- Indicate whether the mother was enrolled in the PHRM/ISS program by checking 'Yes' or 'No'.
- Fill in the mother's name and/or Medicaid number as required.
- Record the positive or negative risk screen date based on the screening outcome.
- Provide details for the referring provider, including their name, telephone number, and appointment date.
- Ensure that the provider signs the form with their professional title, telephone number, and address.
- Follow office mechanics for filing: retain a copy in the infant’s chart for positive screens and keep it updated for negative screens as needed.
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A. A medical risk screen must be conducted to determine the need to refer an individual for Targeted Case Management (TCM) services.
This screen is used to identify infants in their first year of life, whose medical status places them at high risk for mortality and/or morbidity. Instructions:.Read more