Epsdt forms pdf 2026

The document outlines the AHCCCS EPSDT Tracking Forms, which are mandatory for providers to document age-specific information related to EPSDT screenings and visits. It specifies that only AHCCCS forms are acceptable, with guidelines for electronic substitutes. The document details the requirements for tracking forms, including necessary fields, distribution protocols, and responsibilities of providers and contractors. It emphasizes the importance of these forms in ensuring preventive care services for members and provides contact information for further inquiries.

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Click ‘Get Form’ to open the EPSDT Tracking Form in the editor.
Begin by entering the patient's last name, first name, and date of birth in the designated fields. Ensure accuracy as this information is crucial for tracking.
Fill in the primary care provider's details, including their phone number and any medications the patient is currently taking.
Complete the health assessment sections, including vital signs like temperature, pulse, and weight. Use the provided checkboxes to indicate any concerns or observations.
For each developmental milestone section, mark accomplishments and guidance given using the checkboxes. This helps document progress effectively.
Review all entries for completeness and accuracy before saving or printing the form. Ensure that all required signatures are included.

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What does EPSDT mean in medical terms?

A. EPSDT stands for Early and Periodic Screening, Diagnostic and Treatment. The EPSDT benefit provides comprehensive and preventive health services for children under age 21 who are enrolled in Medicaid.

What is the modifier for the EPSDT?

If the first 5 or more components of an HCY/EPSDT screen are completed, you may bill using the age appropriate CPT code, EP modifier (along with modifier 52 to identify a partial screen was performed), and appropriate ICD-10 code to count toward your Participation Rate.

Which of the following are required components of EPSDT?

EPSDT is made up of the following screening, diagnostic, and treatment services: Screening Services. Vision Hearing Services. Dental Services. Lead Screening. Immunizations/Vaccines for Children (VFC) Program. Other Necessary Health Care Services. Diagnostic Services. Treatment.

When should the EP modifier be used?

How is the EP modifier used? Early and Periodic Screen, therefore any service provided in an Early and Periodic Screen should have an EP modifier. It is important to append an EP modifier to these services, as some of these CPT codes are also used for services provided to adults.

What is modifier tj used for?

Modifiers ModifierDescription TJ Program group, child and/or adolescent U1 Nonelective Cesarean Section (locally defined for physicians) U5 Intrathecal Infusion Pump-Trial (locally defined for physicians) UD Clozapine Management (locally defined)4 more rows