WVDHHR > HealthCheck > Provider Information

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:

Print all HealthCheck Forms
Prior Authorization Forms

The WV EPSDT Preventive Health Screening Forms will no longer be stocked in the warehouse. We ask that you download and
print the forms. However, if you are unable to, please reach out to your local Program Specialist.

Health History Form 0-6 years	Health History Form 7-20 years	Newborn to 1 Week Form
By 1 Month 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 & 6 Year Form	7 & 8 Year Form	9 & 10 Year Form
11-14 Year Form	15-17 Year Form	18-20 Year Form