Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |EPSDT Screening Report |

|Child’s Name: |      |DOB: |      |

|TFACTS ID#: |      |Home County: |      |

|Date of EPSDT: |      |Facility: |      |

EPSDT Required Components:

| |1. Comprehensive history (incl. developmental and behavior screening) | Yes No |

| |2. Physical examination (unclothed) | Yes No |

| |3. Hearing assessment | Yes No |

| |4. Vision assessment | Yes No |

| |5. Laboratory testing | Yes No |

| |6. Health education | Yes No |

| |7. Immunizations up-to-date | Yes No Record not available |

|Height: |      |Weight: |      |

If TB skin test positive, was health department notified? Yes No

Referrable conditions: Yes No

|Details: |      |

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Have appointments been made for referable conditions? Yes No

|Please list any appointments scheduled as a result of EPSDT findings today: |      |

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|Additional comments: |      |

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Healthcare Provider Details

| | |

|Clinic Name: |      |

| | |

|Street Address: |      |

| | |

|City, State, Zip: |      |

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|Telephone Number: |      |

|Healthcare Provider Name (Print) | |Date: | |

|Healthcare Provider Signature | |

EPSDT Screening Report

The completed form is forwarded to the appropriate DCS Health Unit

| |Davidson |900 2nd Avenue North | |Smoky Mountain |613 West Hwy 11E Ste #1 New Market, TN |

| | |Nashville, TN 37243 | |Counties: Claiborne, Cocke, |37820 |

| | |Telephone: 615-253-1963 | |Grainger, Hamblen, Jefferson, |Telephone: 865-471-1644 |

| | |615-350-4113 | |Blount Sevier |865-471-6978 |

| | |Fax: 615-253-2509 | | |Fax: 865-594-2623 |

| |East |182 Frank Diggs Dr . # 100 | |South Central |1400 College Park, #A |

| |Counties: Anderson, Campbell,|Clinton, TN 37716 | |Counties: Bedford, Coffee, , |Columbia, TN 38401 |

| |Loudon, Monroe, Morgan, |Telephone: 865-425-4471 | |Franklin , Giles, Grundy, Hickman,|Telephone: 931-490-6078 |

| |Roane, Scott, Union |Fax: 865- 463-8402 | |Lawrence, Lewis, Lincoln, Marshall,|931-490-6087 |

| | | | |Maury, Moore, Perry, Wayne |Fax: 931-380-3346 |

| |Knox |2600 Western Ave. | | Southwest |Lowell Thomas State Bldg |

| | |Knoxville, TN 37921 | |Counties: Chester, Decatur, |225 Dr. MLK Drive, 3rd flr |

| | |Telephone: 865-594-5389 | |Fayette, Hardeman, Hardin, Haywood,|Jackson, TN 38301 |

| | | | |Henderson, Lauderdale, Madison, |Telephone: 731-421-2139 |

| | |Fax: 865-525-7198 | |McNairy, Tipton |731-421-2140 |

| | | | | |Fax: 731-265-2016 |

| |MidCumberland |200 Athens Way, Suite #2A | |Tennessee Valley/ Hamilton |5600 Brainerd Rd. #602 C |

| |Counties: Cheatham, |Nashville, TN 37243 | | |Chattanooga, TN 37411 |

| |Montgomery, Robertson, |Telephone: 615-360-4385 | | |Telephone: 423-634-3147 |

| |Rutherford, Sumner, |615-360-4384 | | |Fax: 423-296-9134 |

| |Trousdale, Williamson, Wilson|Fax: 615-253-5648 | | | |

| |Northeast |2555 Plymouth Rd. | |Tennessee Valley/ Southeast |5600 Brainerd Rd. #C-20 |

| |Counties: Carter, Greene, |Johnson City, TN 37601 | |Counties: Bledsoe, Bradley, McMinn,|Chattanooga, TN 37411 |

| |Hancock, Hawkins, Johnson, |Telephone: 423-979-5228 | |Marion, Meigs, Polk, Rhea, |Telephone: 423-296-2331 |

| |Sullivan, Unicoi, Washington |Fax: 423-585-3410 | |Sequatchie |Fax: 423-296-8370 |

| |Northwest |8600 Highway 22 | |Upper Cumberland |600 Hearthwood Court Cookeville, TN |

| |Counties: Benton, Carroll, |Dresden, TN 38225 | |Counties: Cannon, Clay, Cumberland,|38506 |

| |Crockett, , Dickson, Dyer, |Telephone: 731-365-4543 | |DeKalb, Fentress, Jackson, Macon, |Telephone: 931-646-3025 |

| |Gibson, Henry, Houston, |Fax: 731-364-3673 | |Overton, Pickett, Putnam, Smith, |Fax: 931-372-2513 |

| |Humphreys, Lake, Obion, | | |Van Buren, Warren, White | |

| |Stewart, Weakley | | | | |

| |Shelby |One Commerce Square | | | |

| | |40 South Main, Suite 600 | | | |

| | |Memphis, TN 38103 | | | |

| | |Telephone: 901-348-3663 | | | |

| | |Fax: 901-396-1462 | | | |

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