CM02: Goals Care Plan: CM02-03 CM03: Planned Services 814: EI if indicated by dev screen or other health provider (PA15, F2 to) 819: WIC if appropriate 822: Specialist if indicated 906: DCFS Nurse if medically complex Referrals and 907: APORS or HRIF if eligible Follow-up: RF01-03 DSCC Referral if medically complex 804: Family Planning Other Referrals: List Verify with SCG receiving services Comp Health Profile 5.1 or CHE form (CFS 653) HWLA IMCM Health Summary (CFS 497IIID) records Past medical records or attempts on file IA Summary sent to PCP Medical SCG contacted Needs Identified SV01: 806 or 802 - EPSDT age appropriate or prenatal visits SV01:827 Dental 2y & prophylaxis q. 6 mo SV01:828 Vision 3, 4 & 5 y SV01:829 Hearing 4 & 5y PA19: ACR Cycle (list months) Health Summary SV02: Health Summary sent to Caseworker Form for a month prior to ACR every 6 months ACR or Transfer SV02: Transfers: Sent to new MCMA and /or HWLA and Caseworker if transferred SV02: Health Summary Transfer Form sent to Caseworker and HWLA at age 6 (Cook Co: sent to HWLA) Case Closure PA15: Reason for Closure (if YES, Sources for continued services complete) Report of Prenatal Care Services & Pregnancy Outcomes sent to HWLA [Cook – Co only]
Care Plan: CM02-03 CM02: Goals CM03: Planned Services Referrals and Follow-up: RF01-03 814: EI if indicated by dev screen or other health provider (PA15, F2 to) 819: WIC if appropriate 822: Specialist if indicated 906: DCFS Nurse if medically complex 907: APORS or HRIF if eligible DSCC Referral if medically complex 804: Family Planning Other Referrals: List Verify with SCG receiving services Medical Needs Identified HWLA IMCM records on file Comp Health Profile 5.1 or CHE form (CFS 653) Health Summary (CFS 497IIID) Past medical records or attempts IA Summary sent to PCP SCG contacted SV01: 806 or 802 - EPSDT age appropriate or prenatal visits SV01:827 Dental 2y & prophylaxis q. 6 mo SV01:828 Vision 3, 4 & 5 y SV01:829 Hearing 4 & 5y Health Summary Form for ACR or Transfer PA19: ACR Cycle (list months) SV02: Health Summary sent to Caseworker a month prior to ACR every 6 months SV02: Transfers: Sent to new MCMA and /or HWLA and Caseworker if transferred Case Closure (if YES, complete) SV02: Health Summary Transfer Form sent to Caseworker and HWLA at age 6 (Cook Co: sent to HWLA) PA15: Reason for Closure Sources for continued services Report of Prenatal Care Services & Pregnancy Outcomes sent to HWLA – [Cook Co only]
FY18_HWIL_Chart_Review_Tool_0-5years_pregnant_Final-5-23-2017.docx