Screening Form - Florida Department Of Health

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CMS CLINICAL ELIGIBILITY SCREENING FORM
DEMOGRAPHIC INFORMATION
Interpreter Services Needed (Language Preference or Hearing Impaired):
Referral Source: _______
Screening Conducted: By telephone  In person  Other  ______
Date Referred: _________
Race:___ Sex: F  M 
Child’s full name (Last, First, MI)
Social Security Number:
Date of Birth:
Name of Person Answering Questions:
Relationship to child:
Child’s Mailing Address:
Child’s Physical Address:
Parent/Legal Guardian E-mail Address:
Home Phone:
Work Phone:
Cell Phone:
To the best of your knowledge, based on information received from a health care provider, does your
child have a condition which is both chronic (meaning expected to last 12 or more months) and is a
serious, physical developmental, behavioral, or emotional condition which requires health care and
related services of a type of amount beyond that which is generally required by children?
Yes – Parent believes child has a special health care need—GO TO QUESTION 1
No – End of intake screening—FOLLOW INSTRUCTION IMMEDIATELY BELOW
 YES – Continue to Question 1
 NO – End Screening
Form DH8000 (12/2015)
Rule 64C-2.002, Florida Administrative Code
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