AHCCCS Medical Policy Manual
Appendix B - Early and Periodic Screening Diagnosis and Treatment Tracking Forms

Appendix B of the AHCCCS Medical Policy Manual contains several Early and Periodic Screening Diagnosis and Treatment Tracking Forms for specific time periods. Select an individual Portable Document Format (PDF) form from the table below, or ...

...a complete package of these Tracking Forms is also available by using the Zip file link below. (This is a zip file of PDF files.)

EPSDT Tracking Forms Zip File [PDF 692.34 Kb]

...or, all of the forms are available in one PDF file by clicking on the link below:

All EPSDT Tracking Forms [PDF 707.29 Kb]

Individual PDF Forms:

Overview - Read This First
Two (2) to Four (4) Days	Twelve (12) Months	Five (5) Years
One (1) Month	Fifteen (15) Months	Six (6) Years
Two (2) Months	Eighteen (18) Months	Seven (7) to Eight (8) Years
Four (4) Months	Twenty-Four (24) Months	Nine (9) to Twelve (12) Years
Six (6) Months	Three (3) Years	Thirteen (13) to Seventeen (17) Years
Nine (9) Months	Four (4) Years	Eighteen (18) to Twenty-One (21) Years

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AHCCCS Medical Policy Manual Appendix B - Early and Periodic Screening Diagnosis and Treatment Tracking Forms

AHCCCS Medical Policy Manual
Appendix B - Early and Periodic Screening Diagnosis and Treatment Tracking Forms