Get New Hampshire Confidential Std Reporting Form - Dhhs Nh

Filling out the New Hampshire Confidential STD Reporting Form online is essential for maintaining confidential health records. This guide will walk you through each step of the process, ensuring that you provide accurate and complete information.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in a suitable format for editing.
2. Begin by filling in the patient information section. Enter the last name, first name, and middle initial in the appropriate fields, along with the date of birth in the format MM/DD/YYYY. Include the patient's address, city, state, zip code, and employer details.
3. Provide the home phone, cell phone, and work phone numbers of the patient. Specify the patient's sex and indicate their race and ethnicity. If applicable, note the due date for any pregnant individuals.
4. Indicate the marital status of the patient and primary language spoken. Be sure to check all relevant boxes for sexually transmitted disease testing performed by your facility, including the specific conditions associated with symptoms.
5. For each test performed, include the date of the test, the reporting lab, and the result (either positive or negative). Also, specify the specimen source taken for testing.
6. Detail any non-treponemal or treponemal tests that were conducted, including their respective dates and reporting labs, along with the results.
7. Select all applicable treatments the patient has received, noting the treatment dates along with any special considerations for pregnant individuals.
8. Confirm whether the patient was tested for HIV; if yes, also record any treatments provided.
9. Fill in the partner information section by indicating the partner's sex and the number of partners the patient has had in the past 12 months. Note if the partner was treated or referred for treatment.
10. Provide additional notes if necessary, and finalize the form with the healthcare provider's name, facility, and contact information. Include the person reporting the case and the date of reporting.
11. After completing all sections, save the changes made to the form. You may also choose to download, print, or share the form as required.

Complete your forms online today for prompt and confidential reporting.