Get 401 222 7543

Filling out the 401 222 7543 form online is a crucial step in the reporting process for HIV cases. This guide provides a clear and supportive approach to ensure that all users can complete the form accurately and effectively.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in the patient information section. Record all dates in mm/dd/yyyy format. Provide the patient’s first name, middle name, last name, and any alternate name types, if applicable.
3. Complete the address section. Specify the type of address (e.g., residential, correctional facility) and provide the current street address, city, county, state/country, and ZIP code.
4. Input the facility providing information. Enter the facility name, contact phone number, and street address. Specify whether it is an outpatient or inpatient facility.
5. In the patient demographics section, indicate the sex assigned at birth, country of birth, date of birth, and current gender identity. Provide expanded ethnicity and race as applicable.
6. Complete the reporting/diagnosing provider information. Provide the provider’s name, specialty, and the facility of diagnosis. Indicate the diagnosis type (HIV or AIDS).
7. Respond to all patient history questions, ensuring to check yes, no, or unknown as applicable, and provide details in comments where required.
8. Fill out the laboratory data section, entering relevant details for HIV antibody tests, HIV detection tests, and immunologic tests as required.
9. Complete any necessary treatment/services referrals, indicating if the patient has been informed of their HIV infection and any relevant partner notification details.
10. Finally, review all entered information for accuracy and completeness. Once all information is filled out, you can save changes, download, print, or share the form as needed.

Complete your documents online today for a seamless experience.