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reventable Conditions. Visit Reporting of Provider Preventable Conditions for DHCS instructions for online reporting. By clicking on these links, you will be leaving the IEHP website. Medicare Outpatient Observation Notice (MOON) In the event any Medicare recipient has been in a status of outpatient observation for greater than 24 hours, Acute Hospitals are required to provide Medicare Members with a Medicare Outpatient Observation Notice (MOON). Medicare recipients must receive the MOON within 36 hours of admission to observation level of care. Please refer to the following website for further details on MOON requirements at https://www.federalregister.gov/articles/2016/08/22/2016-18476/medicare-program-hospital-inpatient-prospective-payment-system-for-acute-care-hospitals-etc.  By clicking on this link, you will be leaving the IEHP website. Document Catalog: MOON FAQs (PDF) MOON Instruction Summary (PDF) CMS Manual System 10611_Pub 100-04 Medicare Claims Processing MOON Instructions (PDF) MOON Forms MOON English (PDF) MOON Spanish (PDF) MOON Correspondence (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

otices from most recent P&T Formulary changes to current PER processing changes, and even CME event invitations.  The published notifications are grouped respectively for: Provider Communication - Pharmacy Provider Communication - Physician

e January 1, 2022, the Medi-Cal pharmacy benefits and services are administered by DHCS in the Fee-For-Service (FFS) delivery system, known as "Medi-Cal Rx." Magellan Medicaid Administration, Inc. (MMA) assumes operations for Medi-Cal Rx on behalf of the State of California Department of Health Care Services (DHCS). How to Register for the User Administration Console (UAC) (PDF) User Administration Console (UAC) Quick Start Guide (PDF) Medi-Cal Rx 101 Webinar Presentation (PDF) IEHP and DHCS strongly recommends our Providers to visit the new Medi-Cal Rx website (https://medi-calrx.dhcs.ca.gov) to register for the Magellan Medi-Cal Rx portal, review schedule of trainings available on the new Medi-Cal Rx Portal, and review general information about the transition. Communication from DHCS Please refer to the DHCS Medi-Cal Rx: Transition and DHCS Medi-Cal Provider Pharmacy News Bulletins pages for additional information.   Communication from IEHP While you can always refer to Pharmacy Communication and Provider Correspondence pages, the below list is provided for your convenience. January 02, 2023 - IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance (PDF) December 22, 2022 - Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition (PDF) October 28, 2022 - Cal MediConnect to Medi-Cal RX Transition (D-SNP) (PDF) July 29, 2022 - NEW DATE: Medi-Cal RX Gradual Reinstatement of Prior Auths (PAs) – Phase 1 – September 16, 2022 (PDF) July 13, 2022 - DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80 (PDF) July 11, 2022 - Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1 (PDF) June 03, 2022 - Medi-Cal RX Transition: Blood Pressure Monitors and Cuffs (PDF) June 03, 2022 - Medi-Cal RX Billing Policy for Physician Administered Drugs (PADs) (PDF) February 17, 2022 - RETRACTION - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM - PCP) (PDF) February 17, 2022 - RETRACTION - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM - IPA)  (PDF) February 14, 2022 - Medi-Cal Rx Transition Survey - Your Response is Important! (PDF) February 11, 2022 - Updated - Medi-Cal Rx Transition - Implantable and Injectable Contraceptives FAQs (PDF) February 09, 2022 - Medi-Cal Rx Transition - Hyaluronic Acid Knee Injections (PDF) February 07, 2022 - Medi-Cal Rx UPDATE: Revised Prior Auth Policy for Prescribers and Emergency Fill Quantity Limit (PDF) February 07, 2022 - Medi-Cal Rx Transition - How To Assist IEHP Members (PDF) January 18, 2022 - Medi-Cal Rx Transition - Implantable and Injectable Contraceptives (PDF) January 18, 2022 - Medi-Cal Rx (Magellan) Customer Service (PDF) January 18, 2022 - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM) (PDF) January 04, 2022 - CORRECTION! Medi-Cal Rx: Mail Order for Blood Pressure Monitors and Nebulizers (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

nd Empire Health Plan (IEHP) is now responsible for coverage of the Major Organ Transplant (MOT) benefit for adult and pediatric transplant recipients and donors, including related services such as organ procurement and living donor care.   What Transplant Services are Available for Members? Autologous Islet Cell Bone Marrow Cornea Heart Heart-Lung Liver Liver-Heart Liver-Intestinal Liver -Lung Lung Kidney Kidney-Liver Kidney - Pancreas Pancreas (after Kidney)   Centers of Excellence (COE) For transplant care, IEHP has partnered with various, local, Centers of Excellence (COE). A COE is a recognized program within an existing healthcare center that provides a concentration of specialized care,  delivered in a comprehensive, interdisciplinary manner. Their focused care in distinct areas provides exceptional, integrated care that can lead to better Member outcomes.   Bone Marrow - CHLA, City of Hope, LLUMC, UCSD, USC (Norris) Heart - USC (Keck), LLUMC, Rady's Children, Sharp Memorial, UCSD Intestinal - CHLA Kidney-Pancreas - LLUMC, UCI Liver- CHLA, LLUMC, USD, USC (Keck) Lung - UCSD      You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here  

ticipating Orthopedist for global fracture care without a prior authorization.  This Program ensures that Members in need of fracture care by an Orthopedist, as determined by an Emergency Department Physician, Urgent Care Physician or Primary Care Provider, will receive timely access to care. Policy Reference: 10 - Medical Care Standards Total Fracture Care Providers Arrowhead Orthopaedics  For more information and locations, please visit: https://www.arrowheadortho.com/ Newport Care Medical Group For more information please call: (951) 363-5064   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Medi-Cal y Medicare, es posible que sea elegible para inscribirse en el plan IEHP DualChoice (HMO D-SNP). Nuestro plan IEHP DualChoice lo ayuda a obtener la atención que necesita para lograr su mejor salud posible. Obtenga beneficios cubiertos por $0 incluyendo: Citas médicas como chequeos de rutina y citas por enfermedad Recetas médicas de la lista de medicamentos cubiertos de IEHP DualChoice Atención en el hospital como servicios de urgencia y sala de emergencias, que son actualmente elegibles para Medi-Cal  Atención de especialistas ADEMÁS, beneficios adicionales como: Cuidado de la vista: Límite de $350 cada dos años para lentes de contacto y anteojos (armazón y lentes) Asignación de $40 para servicios cubiertos. Debe calificar para este beneficio. ¿Quién es elegible para IEHP DualChoice (HMO D-SNP)? IEHP DualChoice es para personas que tienen Medicare (Parte A y B) y Medi-Cal. La siguiente información explica quién califica para IEHP DualChoice (HMO D-SNP). Población incluida: Con inscripción obligatoria para beneficios de Medi-Cal, incluyendo beneficios de servicios y apoyo de largo plazo (Long-Term Services and Supports, LTSS) y beneficios de Medicare. Usted es elegible para nuestro Plan siempre y cuando: viva en nuestra área de servicio (no se considera que las personas encarceladas viven en el área de servicio geográfica incluso si estan físicamente en ella); sea mayor de 21 años en el momento de la inscripción;  tenga Medicare Parte A y Medicare Parte B; sea actualmente elegible para Medi-Cal; sea beneficiario dual elegible para todos los beneficios y se inscriba en IEHP DualChoice para sus beneficios de Medicare y en Inland Empire Health Plan (IEHP) para sus beneficios de Medi-Cal. Esto se conoce como “inscripción exclusivamente alineada”; y sea ciudadano de los Estados Unidos o esté de manera legal en los Estados Unidos. Para inscribirse, llame al Equipo de Medicare de IEHP DualChoice al 1-800-741-IEHP (4347), 8am – 8pm, los 7 días de la semana, incluyendo los feriados. Los usuarios de TTY deben llamar al 1-800-718-4347. Formulario de inscripción en IEHP DualChoice IEHP DualChoice (HMO D-SNP) es un Plan HMO con un contrato con Medicare. La inscripción en IEHP DualChoice (HMO D-SNP) depende de la renovación del contrato. La información en esta página está vigente desde el 01 de octubre de 2022. H8894_DSNP_23_3241532_M Pending Accepted

ant to the Department of Health Care Services (DHCS) APL 21-014 (PDF), “Alcohol and Drug SABIRT,” IEHP has updated its requirements for alcohol and substance use screening in the primary care setting. Helpful resources: Correspondence - June 2022 - Alcohol and Drug SABIRT Training Guide (PDF) Screening Tools Alcohol Use Disorders Identification Test (AUDIT-C) Brief Addiction Monitor (BAM) (PDF) Cut Down-Annoyed-Guilty-Eye-Opener Adapted to Include Drugs (CAGE-AID) (PDF) Tobacco Alcohol, Prescription Medications and other Substances (TAPS) (PDF) National Institute on Drug Abuse (NIDA) Quick Screen for Adults (PDF) Drug Abuse Screening Test (DAST-10) (PDF) Parents, Partner, Past, and Present (4Ps) for pregnant women and adolescents (PDF) Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) for non-pregnant adolescents (PDF) Michigan Alcoholism Screening Test Geriatric (MAST-G) alcohol screening for geriatric population (PDF) Assessment Tools Alcohol Use Disorders Identification Test (AUDIT) (PDF) Brief Addiction Monitor (BAM) (PDF) NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test (NM-ASSIST) (PDF) Drug Abuse Screening Test (DAST-20) (PDF) Pamphlets Riverside Brochure (English) (PDF) Riverside Brochure (Spanish) (PDF) San Bernardino Brochure (English) (PDF) San Bernardino Brochure (Spanish) (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

fornia Physician Orders for Life Sustaining Treatment (POLST) Registry (CPR) to connect a digital POLST network throughout the Inland Empire Healthcare System which includes independent physicians, hospitals, skilled nursing facilities, and the Health Information Exchange (HIE). The goal of this initiative is to provide a more effective means of documenting, communicating, and ensuring Member desired Treatment at the end of life is being honored.  By clicking on these links, you will be leaving the IEHP website. To login, visit Working Toward a Statewide POLST Registry in California | POLST (capolst.org) To sign up, simply go to POLST for Healthcare Providers | POLST (capolst.org) CPR Correspondence (PDF) CPR FAQ (PDF) For any questions, please contact Care Directives at (888) 621-4383 or email support@caredirectives.org. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

als who are dual eligible for both Medicare and Medi-Cal in Riverside and San Bernardino counties, including the most vulnerable population. This also includes members transitioning from IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan). IEHP has identified the most vulnerable as the following: Age 21-70 Identified as High and Rising Risk Diagnosed with Cardiovascular Disease AND/OR Diabetes RUB Score of 4 & 5. *RUB is Resource Utilization Band which is a predictor of using acute or costly services. IEHP will identify the most vulnerable members assigned to IPAs IEHP and its IPAs must design care management specific interventions to demonstrate how they support these member's health and wellness goals. Examples of Specially Tailored Services for the Most Vulnerable Population Remote Patient Monitoring Medically Tailored Meals and Other Community Supports Nutrition Education Pharmacy Services (medication reconciliation and other programs) Long-Term Services and Supports (LTSS) Telehealth Behavioral Health Services Transportation More frequent care management contact IEHP DualChoice (HMO D-SNP) Model of Care Training   The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS) and the National Committee for Quality Assurance (NCQA) require that IEHP staff and contracted consultants/vendors, our Medicare IPAs, Hospitals/SNFs, and Providers, receive training on the Plan’s Model of Care for our D-SNP Members: Interdisciplinary Care Team (ICT) Fact Sheet (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML)   *We recommend opening file in: Mozilla Firefox, MS Edge, Chrome or MS Internet Explorer    You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

gram, Prior Authorization Criteria, Clinical Practice Guidelines, Forms, IEHP Formulary, and Safety Resources with drug recall information. If you have any questions regarding services provided by the Pharmaceutical Services Department, please feel free to contact the IEHP Pharmacy Department at (909) 890-2049. Pharmaceutical Services

ude printable reference documents for your convenience and ease of use. Go to the Quality & Clinical Resources and Tools page. In this section find information regarding Clinical Practice Guidelines. Safety Resources

P DualChoice (HMO D-SNP) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. It is an organization made up of doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. It also has care coordinators and care teams to help you manage all your providers and services. They all work together to provide the care you need.   What is the goal of this program? The goal is to improve care by integrating the following healthcare services: Medicare and Medi-Cal benefits Long-term care Behavioral health Home and community-based services (HCBS) such as Community-Based Adult Services (CBAS) and Multipurpose Senior Services Program (MSSP). Who is eligible for IEHP DualChoice (HMO D-SNP)? People who have both Medicare and Medi-Cal. For a complete list of who is included or excluded, visit Who Qualifies?   Plans and Benefits IEHP DualChoice (HMO D-SNP) integrates healthcare services to better coordinate care and improve health.   How to Enroll To enroll, please call: IEHP DualChoice (HMO D-SNP) Team at 1-800-741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347, OR Health Care Options (HCO) at 1-844-580-7272, 8am – 5pm (PST), Monday – Friday. TTY/TDD users should call 1-800-430-7077. For more information, visit the DHCS website. By clicking on this link, you will be leaving the IEHP DualChoice (HMO D-SNP) website. You may also call IEHP DualChoice (HMO D-SNP) for help at 1-877-273-IEHP (4347), 8am – 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347 (4347). Plan Benefits and Cost-Sharing: Find out about plan benefits which are the types of medical care that are covered. Also view information on cost-sharing which is how much you will pay for services or prescription drugs, including monthly plan premium and co-payment. Part D Prescription Drugs: Get information on pharmacy benefits, IEHP network pharmacies, out-of-network coverage, pharmacy transition process, drug utilization management, and prescription mail order. Provider Access Information: Learn about network providers, primary care providers, specialists and how to choose a provider in our network. Read about our quality assurance activities and find out what happens if your doctor leaves our plan. Grievances, Coverage Determination and Appeals Process: Find out what to do if you have a problem or complaint about your medical care or Part D. Helpful Information: View your rights and responsibilities upon disenrollment and as a Member of IEHP. You will also find important forms, such as our Privacy Notice, Plan Transition Process and the section of CMS' website regarding Best Available Evidence. Service Area: Only people who live in our service area can join IEHP DualChoice. Our service area includes all of Riverside and San Bernardino counties.   IEHP DualChoice (HMO D-SNP) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Information on this page is current as of April 19, 2023. H5355_CMC_19_1059755 Accepted      

r Community Affiliated Health Plans (ACAP)

Círculo para Niños Formato: Grupo pequeño Duración: Sesión de 30 minutos Edades: de 0 a 5 años, los niños deben estar acompañados por el padre, la madre o el tutor. Estas clases están diseñadas para familias con bebés, niños y niños de 0 a 5 años. Las clases promueven el desarrollo saludable y las habilidades relacionadas con la formación de los hijos mediante juegos atractivos e interacción social. Los padres son motivados a acceder a recursos de atención medica y trabajar con sus pediatras en las evaluaciones de desarrollo y las intervenciones tempranas. Aprenda sobre la educación para la salud incluyendo temas esenciales como consultas para un bebé saludable, alimentación, desarrollo del lenguaje, seguridad, actividad física y vacunas. Las evaluaciones de desarrollo están disponibles a petición.  Para solicitar una evaluación del desarrollo de su hijo, envíenos un correo electrónico a screening@iehp.org Consulte también: Al hacer clic en los enlaces a continuación usted saldrá del sitio web de IEHP. Etapas del Desarrollo Calendario para las Visitas del Niño Saludable Calendario de Vacunación Citas preventivas para ninos (PDF)    

th us to offer our members the highest quality care and service they need. Facility Site Reviews are the required standards by the California Department of Health Care Services (DHCS)/Medi-Cal Managed Care Division (MMCD) for all primary care provider (PCP) sites. Below you will find various resources in regards to DHCS information, Physical Accessibility Reviews (PARS), Facility Site Review (FSR), and Medical Record Reviews (MRR) as well as IEHP’s addendum tools for your reference. Facility Site Review Training Index: Department of Health Care Services (DHCS) IEHP Addendum Tools PARS Facility Site Review Medical Record Review Department of Health Care Services (DHCS) 2022 Facility Site Review Standards (FSR) (PDF) 2022 Facility Site Review Tool  (FSR) (PDF) 2022 Medical Record Review Standards (MRR) (PDF) 2022 Medical Record Review Tool (MRR) (PDF) APL 22-017 - Facility Site Review and Medical Record Review (PDF) DPL 14-005 - FSR Physical-Accessibility Reviews (PDF) PL 12-006 - Revised FSR Tool (PDF) (Back to Index) IEHP Addendum Tools Att 06 - IEHP Urgent Care Evaluation Tool (PDF) IEHP Interim Review (PDF) (Back to Index) PARS APL with PARS C (PDF) APL with PARS D & CBAS (PDF) PAR-FSR-C_PARS - Survey (PDF) PAR-FSR-D_PARS - Ancillary (PDF) PAR-FSR-E_PARS - CBAS (PDF) (Back to Index) Facility Site Review Menu Click on the following links to jump to that specific section: Facility Site Review Audit Tool Sections Additional Documents Medical Record Review Audit Tool Sections Additional Documents (Back to Index) Access/Safety Facility Site Review Emergency Exit Routes Factsheet (PDF) Evacuation Routes (PDF) Glucometer Log (PDF) Hemocue Log (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Emergency Exit Routes Factsheet (PDF) Pre-filled Emergency Medications Dosage Chart (PDF) Sample Oxygen Tank Set (PDF) Workplace Violence (PDF) (Back to FSR Menu) Adult Preventive Medical Record Review ACES Screening (PDF) Adult Health History (PDF) Adult Sterilization & Special Consent P&P (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) PHQ-2 - Sample (PDF) PHQ-9 - Sample (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Adult (PDF) (Back to FSR Menu) Clinical Services Facility Site Review Checklist for Safe Vaccine Storage and Handling (PDF) Clean and Dirty Sign (PDF) Controlled Substance Distribution Log (PDF) Controlled Substance Narcotic Log (PDF) Monthly Expiration Date & Verification Log (PDF) P&P Distribution of Sample Medications (PDF) Patient Distribution Log for Samples (PDF) Plan for Vaccine Protection in Case of Power Outage (PDF) Radiology - Notice to Employees (PDF) Sample Radiology Inspection Report (PDF) Vaccine Information Sheet (VIS) Protocol (PDF) Vaccine Storage (PDF) (Back to FSR Menu) Coordination of Care Medical Record Review Adult Progress Note - Sample (PDF) Missed Appointment Log - Sample (PDF) Pediatric Progress Note - Sample (PDF) (Back to FSR Menu) Documentation Medical Record Review Adult General Consent to Treat (PDF) Advance Health Care Directive Acknowledgement Form (PDF) CAIR Sharing Request (PDF) General Consent to Treat Minor (PDF) Medical Record Release (PDF) Sample Medication List (PDF) Signature Page - IEHP (PDF) (Back to FSR Menu) Format Medical Record Review Acknowledgment of Receipt of Notice of Privacy Practice (PDF) (Back to FSR Menu) Infection Control Facility Site Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Autoclave Log (PDF) Biohazardous Sign (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Cleaning Schedule (PDF) Communicable Disease (ISOLATION) Protocol (PDF) Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF) Instrument Transportation Log (PDF) Isolation & Transmissions Based Precautions (PDF) OSHA Employee Injury Report Form (PDF) P&P Autoclave (PDF) P&P Autoclaving Instruments in Peel (PDF) P&P Chemical Disinfection (PDF) P&P Cold Sterilization (PDF) P&P Transport for Reusable Instruments (PDF) Reusable Sharps Container (PDF) Safety Needle Fact Sheet (PDF) Sharps Injury Log Sample (PDF) Transfer Stations and Treatment Facilities (PDF) (Back to FSR Menu) OB/CPSP Preventive Medical Record Review CPSP Initial and Trimester Assessment and Care Plan (PDF) CPSP Postpartum Assessment and Care Plan (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) Required Documentation Checklist for OB (PDF) (Back to FSR Menu) Office Management Facility Site Review Access Standards (PDF) After Hour Script (PDF) CLAS Standards (PDF) Confidentiality Form (PDF) Fax Sheet (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Medical Record Release (PDF) Office Hours Sample Form (PDF) On-Call Provider Schedule (PDF) PCP Referral Tracking Log (PDF) Referral Process (PDF) Sample Office Hours (PDF) Wait Time Survey Tool (PDF) (Back to FSR Menu) Pediatric Preventive Medical Record Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) AAP Schedule (PDF) AAP Supplemental Information (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) CDC BMI Growth Chart - Boys (PDF) CDC BMI Growth Chart - Girls (PDF) CDC Growth Chart Head Circumference - Boys (PDF) CDC Growth Chart Head Circumference - Girls (PDF) CDC Growth Chart Weight for Age - Boys (PDF) CDC Growth Chart Weight for Age - Girls (PDF) Child Health History - English (PDF) Child Health History - Spanish (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) General Consent to Treat Minor (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) Oral Health Risk Assessment Tool (PDF) PEARLS Assessment (PDF) PEARLS Teen Self-Assessment (PDF) PHQ-2 - Sample (PDF) PHQ-A - Sample (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Pediatrics (PDF) What Do You Eat (8-19 years) - English (PDF) What Do You Eat (8-19 years) - Spanish (PDF) What Does Your Child Eat (Birth - 8 years) - English (PDF) What Does Your Child Eat (Birth - 8 years) - Spanish (PDF) Youth Nutrition and Activity Assessment (8 - 19 years) (PDF) (Back to FSR Menu) Personnel Facility Site Review Accessibility Obligations of Medical Practices (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Domestic Violence (PDF) Electronic Resources for Required Employee Training (PDF) Employee File Checklist (PDF) IEHP Cultural and Linguistics Training (PDF) IEHP Evidence of Staff Training (PDF) IEHP Grievance Resolution Process - English (PDF) IEHP Grievance Resolution Process - Spanish (PDF) IEHP P&P Child Abuse Reporting (PDF) IEHP P&P Elder or Adult Abuse Reporting (PDF) IEHP P&P Sensitive Services-Access Standards (PDF) Medical Assistant Letter of Competency - Fillable (PDF) Medical Assistant Venipuncture Form (PDF) Medication Administration Procedures (PDF) Mid-level Supervision of Medical Assistant (PDF) Notice to Consumer PA Sign - English (PDF) Notice to Consumer PA Sign - Spanish (PDF) Notice to Consumer Sign - English (PDF) Notice to Consumer Sign - Spanish (PDF) SB697 Practice Agreement (PDF) SOC 341 (PDF) Standardized Procedures for Nurse Practitioner (PDF) Suspected Child Abuse Report (PDF) (Back to FSR Menu) Preventive Services Facility Site Review Pure Tone Audiometer (PDF) Visual Acuity Screen Tips (PDF) (Back to FSR Menu) Additional Documents Facility Site Review IEHP Phone List (PDF) (Back to FSR Menu) Additional Documents Medical Record Review Online Resources for Medical Record Review (PDF) (Back to FSR Menu) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.