Form Cms-416 - Annual Early Ad Periodic Screening Diagnostic And Treatment Participation Report

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0354
FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
Age Groups
State ___________FY _______
Total
<1
1–2*
3–5
6–9
10–14
15–18
19–20
1. Total Individuals
CN
Eligible for EPSDT
MN
TOTAL
2a. State Periodicity
Schedule
2b. Number of Years
in Age Group
1
2
3
4
5
4
2
2c. Annualized State
Periodicity Schedule
3a. Total Months
CN
of Eligibility
MN
TOTAL
3b. Average Period
CN
of Eligibility
MN
TOTAL
4. Expected Number of
CN
Screenings per
MN
Eligible
TOTAL
5. Expected Number
CN
of Screenings
MN
TOTAL
6. Total Screens
CN
Received
MN
TOTAL
CN
7. Screening Ratio
MN
TOTAL
* Includes 12–month visit
Note: “CN” - Categorically Needy, “MN” = Medically Needy
Form CMS-416 (06/99)

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