AGENCY: Southwest Utah Public Health Department (Utah)

SERIES: 16680
TITLE: Child Health Evaluation Care medicaid reimbursement report
DATES: undated
ARRANGEMENT:

DESCRIPTION: This form reports the reimbursements received on claims for physical examinations provided under the Child Health Evaluation (CHEC) program. A medicaid billing form is submitted for each completed examination and the original is submitted to the Utah Medical Assistance Program (UMAP) for reimbursement. This form includes child's name, date service provided, date into program, home address, phone number, medical information and patient identification number.

RETENTION

Retain for 3 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series is proposed and has not yet been approved.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

PRIMARY DESIGNATION

Private

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