Get Dhhs 4121

Filling out the Dhhs 4121 form online can streamline the process of submitting laboratory information. This guide will provide you with clear, step-by-step instructions to help you complete each section of the form accurately and efficiently.

Follow the steps to successfully complete the Dhhs 4121 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the left upper portion of the form. Fill in the patient's last name, first name, and middle initial. Ensure accurate spelling for proper identification.
3. Enter the patient number, which can be the Social Security Number or another unique identifier.
4. Complete the address section by entering the patient's home address below the patient number section, as this is crucial for follow-up purposes.
5. Input the patient's date of birth in the specified format. Remember to include month, day, and year.
6. Indicate the patient's race, Hispanic ethnicity, and sex by checking the appropriate boxes. This data is for statistical purposes.
7. Fill in the county of residence for the patient, utilizing the county code as needed.
8. State whether the patient is a Medicaid client by selecting 'Yes' or 'No.' If 'Yes,' provide the Medicaid number. Additionally, enter the Diagnosis Code or ICD-9 information.
9. Complete the submitter details by entering the federal tax number and the return address in the section labeled 'Send Report To.'
10. Proceed to the right upper portion of the form and check the appropriate specimen type. Enter the date the specimen was collected.
11. Indicate what to examine for by selecting the suspected disease or type of examination required.
12. Fill out the specimen source by checking the corresponding box that best describes the source of the specimen.
13. Provide any special comments or further epidemiological information as required in the respective sections.
14. Once all fields are completed, ensure to review all entries for accuracy. Users can then save the changes, download the form, print it, or share it as needed.

Complete your Dhhs 4121 form online today for a smoother submission process.