Screening Form - Florida Department Of Health printable pdf download

Screening Form - Florida Department Of Health

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

Screening Form - Florida Department Of Health