Tip for State-specific

Well-child screenings are covered at 100% under the ACA with no copay

Tip for State-specific

Developmental screening is recommended at 9, 18, and 30 months — and autism screening at 18 and 24 months

Tip for State-specific

Be honest on screening questionnaires — early detection leads to better outcomes

Maternal & PediatriceasyDoctor signature required

Well-Child Visit / EPSDT Screening Form

State-specific · State Medicaid agencies / AAP

Documentation of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for Medicaid-enrolled children. Covers developmental milestones, vision, hearing, dental referrals, and lead screening.

Form Details

Total fields: 35
Auto-fillable: 22 (63%)
Time without BeneFill: 20 minutes
Time with BeneFill: 6 minutes
Time saved: 14 minutes
Filled by: doctor
Frequency: as needed
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

Completed during well-child visits at the pediatrician's office

Screening questionnaires are typically provided in the waiting room or exam room.

Required Attachments

📎 Completed developmental screening questionnaire (ASQ-3, M-CHAT-R, or similar)
📎 Parent/guardian observations and concerns
📎 Previous screening results (if applicable)

Processing Time

Screening results are reviewed during the visit. If concerns are identified, referrals are made immediately.

What Happens Next

The pediatrician will discuss screening results and provide referrals for further evaluation if needed (Early Intervention, specialists, etc.). Results become part of the child's medical record.

Tips for This Form

✓ Well-child screenings are covered at 100% under the ACA with no copay
✓ Developmental screening is recommended at 9, 18, and 30 months — and autism screening at 18 and 24 months
✓ Be honest on screening questionnaires — early detection leads to better outcomes
✓ You can request a screening at any time if you have developmental concerns, not just at scheduled visits

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Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

WIC Medical Documentation / Nutrition Risk Form

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Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid agencies / AAP or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.