Well Visit Required Components

1
ALLIANCE ONLY EVERY CHILD, EVERY
YEAR Pediatric Well Visit Schedule
Yearly Well Visit for ages 2-21 years

• For Medi-Cal use PM 160
• For Healthy Families and Healthy Kids
• use CMS 1500

Under 1 month
1 - 2 months
4 months
6 months
9 months
12 months
15 months
18 months
Schedule appointments to approximate the
intervals noted above. Intervals do not need to
be exact.
Unlike the state-run CHDP program, the Alliance
will pay fee-for-service for one Well-Care Exam
each calendar year ages 2 to 21.
Well Visit Required Components

• Use above schedule (based on American Academy
  of Pediatrics recommendations) for all Alliance
  members.
• The Alliance covers yearly Well Visits from 2nd
  to 21st birthday.

• 1. Health and Developmental Assessment
• 2. Full Physical Exam, Dental Screening/Referral
• 3. Anticipatory Guidance, Health Safety
  Education