In order to meet AHCCCS requirements, an age-appropriate EPSDT form should be filled out each time a P/GLTC member under 21 years of age is seen for a visit. Please make sure all sections of the form are complete. The forms must be used to document services provided and compliance with AHCCCS standards (please reference the P/GLTC Provider Manual for more information on AHCCCS standards). The form must be signed by the clinician who performs the screening.

Once the form is complete, a copy should be faxed to the P/GLTC EPSDT Coordinator at 520.866.6720.