Early and Periodic Screening, Diagnostic and Treatment Form

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents under age 21 in low-income families includes a broad selection of preventive, diagnostic and treatment services. It also covers regular preventive health care through the Health Check program.

Note: The following form is found on the NCTracks Prior Approval web page

• Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old