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Get General Instructions for DHS 8015

Division’s website, www.med-quest.us, and in the Hawaii State Medicaid Provider Manual. Complete the form using either black or blue ink. When indicated, fill in circles. Do not (√ ) check, (×) cross, or ( ∕ ) line through the circles. Section: Patient Information 1. Fill in date of screening visit (date should match date of service on CMS 1500 Claim form) 2. If the age of the patient on the date of the exam is NOT at the specific age listed in the column, indicate the EPSDT periodic scr.

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