Provider Info

HealthCheck Program

Provider Request Form
Exam Forms

Appendix I  - Provider Request Form - Exam Forms

PROVIDER INFORMATION

Introduction

This Provider Information page is designed to inform and assist medical providers in a variety of ways.

Those medical providers interested in providing HealthCheck services are welcome to review this material and contact us through the 800 number listed or through the Program Specialist in your region. Click on Contact Information.

For current medical providers of HealthCheck services, we have included material which is easily accessed through this web page.

HealthCheck providers must have a Medicaid provider number, as certified by the WVDHHR. HealthCheck providers may be an individual or group of physicians, nurse practitioners or a facility such as a Primary Care Center or Outpatient Clinic that hires appropriate, qualified medical staff to perform HealthCheck screening services. HealthCheck supports the following core values of a medical home:

  • Having a personal physician or primary care provider (PCP) who provides first contact care or a point of entry for new problems,

  • Ongoing care over time,

  • Comprehensiveness of care, and

  • Coordination of care across a person’s conditions, providers and settings.

In this section:

HealthCheck Forms:  Health History & Preventive Health Screen
(All Files are in PDF Format)

0-6 Year - Health History Form
 
7-20 Year - Health History Form 1 Day-4 weeks - Preventive Health Screen
2 Month Preventive Health Screen
 
4 Month Preventive Health Screen 6 Month Preventive Health Screen
9 Month Preventive Health Screen
 
12 Month Preventive Health Screen 15 Month Preventive Health Screen
18 Month Preventive Health Screen
 
24 Month Preventive Health Screen 30 Month Preventive Health Screen
3 Year Preventive Health Screen
 
4 Year Preventive Health Screen 5 Year Preventive Health Screen
6 Year Preventive Health Screen
 
7-8 Year Preventive Health Screen 9-10 Year Preventive Health Screen
11-14 Year Preventive Health Screen
 
15-17 Year Preventive Health Screen 18-20 Year Preventive Health Screen
 

 

HealthCheck
1-800-642-9704

Return to HealthCheck Home Page