Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the infant's name, date of birth, address, and phone number in the specified fields. Ensure all information is accurate and complete.
3. Input the Medicaid number and indicate whether the mother is enrolled in the PHRM/ISS program by selecting yes or no in the provided checkbox.
4. Next, enter the mother's name along with her Medicaid number in the designated fields.
5. Record the dates for both positive and negative risk screens as applicable, making sure these dates are accurate.
6. If the PHRM/ISS program was declined, list the reason for this decision in the specified area.
7. Fill in the pediatrician or primary care provider's name, address, and phone number. Additionally, provide the date of the next appointment.
8. The provider completing the form, such as a physician or nurse, must sign and date the form in the space provided, ensuring their professional title is included.
9. List all significant risk factors by entering the ICD-10 diagnosis codes along with their descriptions in the given sections.
10. Once all sections of the form are completed, review the information for accuracy. After confirming all details are correct, you can save changes, download, print, or share the form as needed.

Complete the MS Infant Risk Screening Form online today to ensure proper identification and care for at-risk infants.