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Click ‘Get Form’ to open the instructions 8016 form in the editor.
Begin by filling in the 'Patient Information' section. Enter the date of the screening visit, ensuring it matches the date on your CMS 1500 claim form.
Proceed to 'Immunizations Given Today'. If immunizations were administered during this visit, select the corresponding circle(s). If none were given, leave this section blank.
In the 'Screening Done Today' section, record results for vision and audiometry screenings by selecting the appropriate circles. Use validated tools as recommended.
If developmental or autism screenings were conducted, fill in their results accordingly. If no screenings occurred, leave this section blank.
For 'Referrals Made Today', indicate any referrals by selecting the relevant circles and listing programs or specialties along with a contact number for follow-up.
Finally, complete the 'Provider Statement' by signing and entering your NPI number to finalize the form.

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