April 01, 2022

Arizona: Updated EPSDT clinical sample templates available now

Updated versions of Arizona Health Care Cost Containment System (AHCCCS) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) clinical sample templates are now available. The updated version of these forms can be found in the Provider Forms, Programs and References section of under “General Forms”.

These templates may be used by all providers offering care to AHCCCS members under 21 years of age to document age-specific information related to EPSDT screenings and visits. Providers may choose to use an AHCCCS form, or an equivalent form approved by the contracted health plan, so long as the form includes all components present on the AHCCCS EPSDT Clinical Sample Templates.

If you have questions, please call Provider Services at 800-445-1638.