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Provider Information

The HealthCheck Program works to equip West Virginia's Medicaid providers with the necessary tools and knowledge to carry out EPSDT services appropriate to the American Academy of Pediatrics' standard for pediatric preventive health care, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.

This section of the web site includes resources and materials which support these standards and are easily accessible.

HealthCheck Health History and Preventive Health Screening Forms: 

Health History Form 0-6 years    

Health History Form 7-20 years  1 Day-4 Weeks Form 
2 Month Form 4 Month Form             6 Month Form 
9 Month Form  12 Month Form 15 Month Form
18 Month Form  24 Month Form  30 Month Form 
3 Year Form  4 Year Form  5 Year Form 
6 Year Form  7 & 8 Year Form  9 & 10 Year Form 
11-13 Year Form  14-17 Year Form      18-20 Year Form
















Print all HealthCheck Forms
Prior Authorization Forms

To order forms, please complete, print and fax the Provider Request Form to OMCFH Materials Management at 304-558-1524

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HealthCheck Program bullet Room 427 bullet 350 Capitol Street bullet Charleston, WV 25301
Phone: 1-800-642-9704