Form ODM03258 "Healthchek and Pregnancy Related Services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Your Information' section. Fill in your first name, last name, case number, date of birth, street address, city, state, zip code, email, and telephone number.
3. Next, provide details for your child or children under the 'Your Child’s Information' section. Include each child's name and their respective SSN or Medicaid billing number.
4. Indicate whether your child is enrolled in a Medicaid managed care plan by selecting 'Yes' or 'No' and providing the plan name if applicable.
5. In the 'Healthchek Screening Services' section, check all services you or your child would like to receive. This includes medical exams and screenings.
6. Complete the 'Healthchek Treatment Services and Transportation to Health Care Appointments' section by checking any additional services needed.
7. Finally, review all information for accuracy before signing and dating the acknowledgment section at the bottom of the form.

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