MHCP Enrolled Providers

Child & Teen Checkups (C&TC) Providers

C&TC Documentation Forms for Providers and Clinics

These forms are age-specific templates, which include all appropriate C&TC screening components. There is a template for each of the recommended 20 visits between 1-2 weeks through 20 years.

0-1 month visit (DHS-4813B)

15 month visit (DHS-4813H)

6-7 year visit (DHS-4813N)

2 month visit (DHS-4813C)

18 month visit (DHS-4813I)

8-10 year visit (DHS-4813O)

4 month visit (DHS-4813D)

2 year visit (DHS-4813J)

11-14 year visit (DHS-4813P)

6 month visit (DHS-4813E)

3 year visit (DHS-4813K)

15-17 year visit (DHS-4813Q)

9 month visit (DHS-4813F)

4 year visit (DHS-4813L)

18-20 year visit (DHS-4813R)

12 month visit (DHS-4813G)

5 year visit (DHS-4813M)

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