Follow the steps to fill out your confidential report form effectively.

1. Press the ‘Get Form’ button to access the report form and open it in your chosen editor.
2. Begin by filling out the patient information section. Input the patient’s last name, first name, middle initial, and date of birth in the specified format (mm/dd/yyyy). Select the appropriate race and ethnicity options, and indicate if the patient is pregnant.
3. Complete the patient’s physical address fields, including street address, city, state, and zip code. Provide both home and mobile phone numbers, if available.
4. Move to the disease information section. Indicate any diagnoses regarding chlamydia, gonorrhea, syphilis, and HIV by checking the relevant boxes and detailing any complications or types of specimens collected.
5. Enter the specimen collection date and select the type of specimen collected for laboratory confirmation of the diagnosis.
6. Fill out the medical facility name and attending health care provider information. If the laboratory name is known, include it as well.
7. In the treatment information section, indicate whether treatment was prescribed. If treatment was provided, list the medications and dosages, as well as details of any directly observed therapy.
8. Indicate if expedited partner therapy (EPT) was provided for sexual partners, along with the number of doses if applicable.
9. Finally, sign the report as the person reporting, filling in your name and the date reported. Ensure you have all required details correct.
10. Review all sections to confirm accuracy and completeness. Once completed, save your changes. You can then download or print the form for submission or share it as needed.

Start your online submission process today to ensure timely reporting!