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Get Health Plan Outreach 2018-2024

screen (for members <21 years old) Parent/Guardian Name: Relationship: Phone # include area code: PCP Name Provider ID#: PCP Contact Person: PCP Contact Phone #: Date sent to GHP: Member is being referred for the following: (A Gateway Health Representative will telephonically contact the member and provide education, assist with scheduling appointments and assist with transportation as appropriate) o o o o o o Over due for EPSDT screen – Last Screen date: _____________ Behind on these immun.

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