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Infant risk screening form - Mississippi Division of Medicaid - medicaid ms 2026

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The Infant Risk Screening Form is designed to identify infants at high risk for mortality and morbidity during their first year of life. It requires demographic information about the infant and mother, screening outcomes, and details of the referring case management agency. The form includes various risk factors affecting infant care and outlines procedures for filing positive and negative screens, as well as retention policies.

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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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