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How do I fill this out?
To fill out this form completely, provide all the requested information and follow the given instructions carefully. Make sure to document vital details accurately. Refer to the back of the form for additional guidelines.
How to fill out the Hawaii Early and Periodic Screening, Diagnosis, and Treatment Form?
1
Complete the patient information section by providing the screening date, age, sex, birthdate, name, and Medicaid/QUEST ID.
2
Record measurements including blood pressure, height, weight, BMI, and head circumference for infants.
3
Document immunizations given today and their status along with any screening results.
4
Indicate any referrals made today and care coordination assistance needed.
5
Sign the provider statement at the end to confirm the completion and documentation of the EPSDT exam activities.
Who needs the Hawaii Early and Periodic Screening, Diagnosis, and Treatment Form?
1
Healthcare providers for documenting the EPSDT exam details.
2
Parents to track their child's health checkup and screenings.
3
Medicaid/QUEST administrators for verifying the compliance of EPSDT services.
4
Care coordinators to assist with referrals and arranging needed services.
5
Dentists to follow up on dental assessments and care for children.
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What are the instructions for submitting this form?
Submit the completed form to the patient's health plan or the corresponding Medicaid/QUEST administration via the following options: Email: submit@healthhawaii.gov, Fax: 808-123-4567, Online submission: healthhawaii.gov/submitform, Physical address: Health Hawaii Office, 123 Health Street, Oahu, HI 96814. Ensure to keep a copy for your records and follow up on the submission status.
What are the important dates for this form in 2024 and 2025?
The important dates for this form include biennial updates and annual submissions before the Medicaid/QUEST deadlines in 2024 and 2025.
What is the purpose of this form?
The purpose of the Hawaii Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Exam form is to ensure thorough documentation of essential health checks for children. Providers use this form to record critical patient information, measurements, immunization statuses, and screening results. This form ensures that children receive timely and comprehensive healthcare services, facilitating referrals, and care coordination for optimal health outcomes.
Tell me about this form and its components and fields line-by-line.
- 1. Screening Date: The date the screening took place (MMDDYY).
- 2. EPSDT Periodic Screening Age: Indication of the screening age being reported.
- 3. Sex: Gender of the child: M, F, O.
- 4. Birthdate: The child’s birthdate in the format (MMDDYY).
- 5. Name: The full name of the child including last, first, and middle initial.
- 6. Medicaid/QUEST ID: Identifier assigned by Medicaid or QUEST.
- 7. Measurements: Blood pressure, height, weight, BMI, and for infants, head circumference.
- 8. Immunizations Given Today: List of immunizations provided during the visit and their status.
- 9. Screening Done Today: Details of various screenings carried out during the visit, marked as normal or abnormal.
- 10. Referrals Made Today: Any referrals made during the visit for further care or services.
- 11. Care Coordination Assistance Needed: Details of any assistance needed to manage medical conditions, transportation, and scheduling.
- 12. Provider Statement: Confirmation by the provider that all required EPSDT exam components were performed and documented.
What happens if I fail to submit this form?
Failure to submit this form can result in missed health care services and delays in treatment for children.
- Missed Health Benefits: Children may not receive timely health screenings and immunizations.
- Delayed Referrals: Essential referrals for specialized care may be delayed, impacting the child's health outcomes.
- Lack of Compliance: Non-compliance with Medicaid/QUEST program requirements can affect funding and support services.
How do I know when to use this form?
- 1. Regular Health Checkups: Document periodic health examinations for children as per EPSDT guidelines.
- 2. Immunizations: Track and document immunizations administered during the visit.
- 3. Developmental Screenings: Record outcomes of developmental and autism screenings conducted.
- 4. Referrals and Follow-ups: Indicate any referrals made for additional health care services and follow-up needs.
- 5. Care Coordination: Detail the assistance required for managing health conditions, transportation, and scheduling appointments.
Frequently Asked Question
How do I fill out the patient information section?
Enter the screening date, age, sex, birthdate, name, and Medicaid/QUEST ID of the patient.
What measurements do I need to record?
Record blood pressure, height, weight, BMI, and head circumference for infants.
How do I document immunizations?
Indicate immunizations given today, their status, and fill out any additional comments if needed.
What screenings should be included?
Include vision screening, blood lead levels, hearing screening, developmental screening, autism screening, and other relevant assessments.
How do I indicate referrals?
Fill out the referrals section with any referrals made today and check if the patient is already receiving state or specialty services.
What is care coordination assistance?
Check if the patient needs help managing medical conditions, arranging transportation, or coordinating appointments and provide the caregiver's contact information.
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