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
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|Clinic Name: | |
| | |
|Street Address: | |
| | |
|City, State, Zip: | |
| | |
|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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