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Please fax completed EPSDT Tracking Forms for HCIC members to EPSDT Coordinator at 855-408-3408.

AHCCCS EPSDT TRACKING FORMS

The Arizona Health Care Cost Containment System (AHCCCS) EPSDT Tracking Forms must be used by all

providers offering care to AHCCCS members less than 21 years of age to document age-specific, required

information related to EPSDT screenings and visits. Only AHCCCS EPSDT Tracking Forms may be used;

paper form substitutes are not acceptable. However, the provider may choose to utilize an electronic EPSDT

Tracking Form generated through AHCCCS (once available) or the provider’s electronic health record

system, so long as the electronic form includes all components present on the AHCCCS EPSDT Tracking

Form. These components include, but are not limited to:

Documentation of comprehensive physical exam (including appropriate weights and vital signs)

Age-appropriate screenings (vision, hearing, oral health, nutrition, developmental, nutritional,

tuberculosis (TB) and lead)

Developmental surveillance

Anticipatory guidance (Age Appropriate Education and Guidance)

Social-emotional health (Behavioral Health) surveillance

Age-appropriate labs and immunizations, and

Medically necessary referrals including those to the member’s dental home starting at 1 year of

age, or sooner as needed, for routine biannual examinations.

Interested persons may refer to Chapter 400 in this Manual for a discussion of EPSDT responsibilities and services.

AHCCCS Contractors are required to print two-part carbonless EPSDT Tracking Forms (a copy for the

medical record and a copy for providers to send to the Contractor’s EPSDT Coordinator) and distribute these

forms to their contracted providers. Providers may also choose to print the EPSDT Tracking Form from the

AHCCCS website.

A copy of the completed EPSDT Tracking Form, signed by the clinician, should be placed in the member's

medical record. Depending on the member’s enrollment status, an additional distributed copy of the EPSDT

Tracking Form may be required, as detailed below.

● For members enrolled with an AHCCCS Contractor, a copy of the completed and signed

form must be sent to that Contractor.

● For AHCCCS Fee-For-Service members [e.g., enrolled in the American Indian Health

Program (AIHP)], the provider should maintain a copy of the EPSDT Tracking Form in

the medical record, but does not need to send a copy elsewhere.

AHCCCS Contractors and AHCCCS medical providers may reproduce EPSDT Tracking Forms as needed.

All others may reproduce the forms with permission of AHCCCS via an approved written request directed

to:

AHCCCS

Division of Health Care Management

CQM/Maternal and Child Health

701 E. Jefferson, Mail Drop 6700

Phoenix, AZ 85034

(602) 417-4410

NOTE: The Centers for Medicare and Medicaid Services require AHCCCS to provide specified services to our

EPSDT population. These EPSDT Tracking Forms have been designed to ensure that needed services are performed,

and that our members are provided an opportunity to receive preventive care. Please do NOT alter or amend these

forms in any way without discussion with our Maternal and Child Health Manager at the address above.

Contact information for AHCCCS Contracted health care plans may be found at

Revised: 04/01/2014, 10/01/2009, 07/01/2001, 11/01/2007, 01/01/2004, 11/01/2003, 06/01/2003

Ahcccs Epsdt Tracking Form - 18-21 Years Old - Arizona Health Care Cost Containment System

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