Download individual appendices from Part D, Div. I, HealthCheck Screening
Services Handbook:
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Appendix 1: HealthCheck Laboratory and
Immunization Codes. (79kb)
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Appendix 1a: HealthCheck Screening
Codes. (48kb)
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Appendix 1b: HealthCheck Screening
CPT Codes. (97kb)
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Appendix 2a: HealthCheck
Referral/Modifier Codes for Claim Sort Indicator "H." (40kb)
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Appendix 2b: HealthCheck
Referral/Modifier Codes for Claim Sort Indicator "P." (49kb)
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Appendix 3: National HCFA 1500 Claim
Form Completion Instructions for HealthCheck Services. (488kb)
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Appendix 4a: National HCFA 1500 Claim
Form Sample - Comprehensive Screen With Immunization, Hemoglobin and Lab Handling Fee
("H" Claim Sort Indicator). (128kb)
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Appendix 4b: National HCFA 1500 Claim
Form Sample - Comprehensive Screen With Problem Identified ("P" Claim Sort
Indicator). (126kb)
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Appendix 4c: National HCFA 1500 Claim
Form Sample - Comprehensive Screen With Pelvic Exam ("P" Claim Sort Indicator).
(126kb)
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Appendix 4d: National HCFA 1500 Claim
Form Sample - Comprehensive Screen With Immunization and Lead Test Given ("P"
Claim Sort Indicator). (123kb)
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Appendix 4e: National HCFA 1500 Claim
Form Sample - Interperiodic Screen With Immunization ("P" Claim Sort Indicator).
(122kb)
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Appendix 4f: National HCFA 1500 Claim
Form Sample - Environmental Lead Investigation ("P" Claim Sort Indicator).
(126kb)
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Appendix 4g: Electronic Media Claims
Sample Screen. (62kb)
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Appendix 5: HealthCheck Periodicity
Table. (121kb)
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Appendix 6: Effective Oral Assessment.
(74kb)
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Appendix 7: HealthCheck Individual
Health History Form. (370kb)
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Appendix 8a: Age-Specific HealthCheck
Food Records. (142kb)
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Appendix 8b: Modified Basic Food
Groups for Children. (75kb)
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Appendix 8c: Daily Food Suggestions
for Infants. (100kb)
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Appendix 9: HealthCheck Adolescent
Review Form. (107kb)
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Appendix 10: HealthCheck Family
History. (72kb)
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Appendix 11: HealthCheck Referral
Form. (20kb)
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Appendix 11a: HealthCheck
Verification Card. (38kb)
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Appendix 12a: WIC Medical Referral
Form - Ages 0-5. (62kb)
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Appendix 12b: WIC Medical Referral
Form - Pregnant or Breastfeeding Women. (60kb)
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Appendix 13: Wisconsin Lead Testing
Resources. (75kb)
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Appendix 13a: Preventing Lead
Poisoning in Young Children. (152kb)
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Appendix 13b: Lead Screening
Guidelines. (46kb)
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Appendix 13c: Lead Screening
Questionnaire. (64kb)
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Appendix 14: High-Risk Factors for
Hearing Loss in Neonates and Infants. (131kb)
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Appendix 14a: Your Child's Speech
and Hearing. (222kb)
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Appendix 15: Screening Schedule for
Pediatric Eye Problems. (96kb)
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Appendix 16: HealthCheck Resource
Guide. (531kb)
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Appendix 17: Allowable Place of
Service and Type of Service Codes. (21kb)
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Appendix 18a: Allowable Place of
Service, Type of Service and Modifier Codes for Claims Received by the Fiscal Agent from
2/15/95 to 6/30/95. (92kb)
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Appendix 18b: Allowable Place of
Service, Type of Service and Modifier Codes for Claims Received by the Fiscal Agent On or
After 7/1/95. (51kb)
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Appendix 19: EMC Questionnaire.
(51kb)
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Appendix 20: Medical Assistance
Vaccine for Children Program Shipping Report and Order Form. (147kb)
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Appendix 21: ACIP Immunization
Schedule. (77kb)
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Appendix 22: Environmental Inspection
Worksheet. (73kb)
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Appendix 23: Instructions for Use of
the STAT-PA System. (172kb)
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Appendix 24: How to Access the
Bulletin Board. (108kb)
