Childhood Screening Web Attestation

Welcome to MHS Health Wisconsin. We thank you for being part of our network of participating physicians, hospitals and other healthcare professionals.

Provider Group *

Provider TIN *

Please provide any additional TINs that should be represented on this form.

TIN 2

TIN 3

TIN 4

TIN 5

Does your TIN serve pediatric patients *

Yes No

I attest that the above TIN(s) is following the Recommendations for Preventive Pediatric Health Care as indicated in the most recent Bright Futures-AAP Periodicity Schedule (link below) *

Agree

Bright Futures/AAP Periodicity Schedule

I attest that the above TIN(s) is using the Instruments for Recommended Universal Screening at Specific Bright Futures Visits as listed in the most recent Bright Futures Toolkit (link below) *

Agree

Bright Futures Toolkit

Please share any screening tools you use.

Form Completed By *

Title *

Email Address *

Phone Number *