Get Covid-19 Positive Test Report Form Rev 4.7.20.docx

This guide provides comprehensive steps for completing the COVID-19 Positive Test Report Form Rev 4.7.20.docx online. By following these instructions, users can accurately report positive COVID-19 test results while ensuring compliance with necessary protocols.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in your online editor.
2. Fill in the 'Current Date' field by entering today’s date.
3. Enter the 'Provider Agency Name' which indicates the organization reporting the case.
4. In the 'Services Provided' section, specify the services your agency offers to the individual.
5. Report the name of the person completing the form in the 'Reported by' field.
6. Provide the 'Agency contact' details for any follow-up inquiries.
7. Fill in the 'Member First Name' and 'Member Last Name' sections with the individual's full name.
8. Input the 'Member ID' number assigned to the person.
9. Indicate the 'Member Age' of the individual.
10. Select the program under which the individual is enrolled, either 'CHOICES' or 'ECF CHOICES.'
11. Choose the 'Group' number that corresponds to the individual, typically between 2-8.
12. Identify the 'Region' where the individual resides, selecting from East, Middle, or West.
13. Enter the 'Date Tested Positive for COVID-19' as the date of the positive test result.
14. Specify the 'Setting Type' referring to where the member was residing when they tested positive.
15. Provide the 'Address of where the member was residing when tested positive.'
16. Respond to whether the member went to a different setting after testing positive by selecting 'Yes' or 'No.'
17. If applicable, indicate the 'Setting Type' and 'Current Address' for the new location.
18. Document the 'Safety precautions being taken' during the individual’s care.
19. Confirm whether the staff who have been in contact with the individual have been notified.
20. Describe the 'Type of service being provided' (e.g., CLS, Home Health).
21. If applicable, list the number of housemates if providing CLS or CLS-FM services.
22. For housemates with a different payor, please list their respective payor sources.
23. State whether the provider has sufficient personal protective equipment (PPE) in accordance with CDC guidance.
24. Confirm notifications are complete to the relevant local health departments and other entities.
25. Finally, provide any 'Outcome/Update/Resolution/Additional Comments' before submitting.
26. Once completed, save your changes, and download or print the form for submission.

Complete your COVID-19 Positive Test Report Form online today to ensure timely reporting.