Get Fillable Dhhs 3707

Filling out the Fillable Dhhs 3707 correctly is essential for submitting blood lead analysis information. This guide provides clear steps for completing the form online, ensuring accurate and efficient submission.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the Fillable Dhhs 3707 and open it in the online form editor.
2. Enter the patient's last name, first name, and middle initial in the designated fields. Ensure the use of approved labels if applicable.
3. Complete the patient's home address, including city, state, and zip code, in the appropriate sections. This information is crucial for follow-up.
4. Input the 'county' of residence and local patient ID number (SSN or unique identifier) in the designated fields.
5. Provide the patient's date of birth in the format MM/DD/CCYY. Avoid indicating age; only include the date of birth.
6. Indicate if the patient is a Medicaid client by selecting 'Yes' or 'No' and entering the Medicaid number if applicable.
7. Fill out the diagnosis code or ICD code in the specified field.
8. Mark the appropriate boxes for race, ethnicity, and sex. These are for necessary statistical purposes.
9. Specify if the patient is a refugee, child, prenatal, or a WIC client, as applicable.
10. Record the specimen collection date and specify if the sample is from a Microtainer or Venous. Indicate whether this is an initial or follow-up blood lead test.
11. Enter the submitter's federal tax number (EIN), including any letter suffix, in the provided space for processing.
12. Review all filled fields for accuracy before finalizing the form. Users can save changes, download, print, or share the completed form.

Complete your Fillable Dhhs 3707 online to ensure accurate submission.