Get Ccepi 1

Filling out the Ccepi 1 form, a Notifiable Conditions Report Form, is crucial for reporting specific health conditions. This guide provides a detailed, step-by-step approach to help you complete the form accurately and efficiently.

Follow the steps to complete the Ccepi 1 form online.

1. Click the ‘Get Form’ button to access the Ccepi 1 online document and open it in your chosen format.
2. Begin by filling in the information for the submitting facility. Include the name of the person submitting the report, their title or department, and a contact telephone number with an extension. Ensure that you either type or affix your official facility stamp or seal in the designated area above.
3. Indicate the notifiable condition you are reporting by selecting either 'Acute Condition' or 'Chronic Condition'.
4. Provide the 'Date Submitted', 'Initial Onset of Symptoms', and 'Diagnosis (Dx) Type'. Choose an option that applies: Clinical, Culture/PCR, Serology, Biopsy/Smear, or Other, and detail the specific diagnosis date.
5. Fill in the name and address of the diagnosing physician. Select the relevant type of practice (Clinic, Hospital, or Office) and provide their contact number.
6. Enter patient details including last and first name, date of birth, and physical address of residence, indicating whether it's a home or facility. Also, provide the patient's city, state, and ZIP code.
7. Complete gender, race, and ethnicity fields as required. Input the patient's home telephone number.
8. If the patient is a minor (under 18 years), include the names and telephone numbers of their parent(s) or guardian(s).
9. Confirm that you have attached any additional documents, such as confirmatory lab results, to the report.
10. Finally, send the completed form via fax to 1-(866)-326-3316 or (956) 361-8296, addressing it to the PHP Program Epidemiology Section. If you need assistance, call (866) 326-3397 or (956) 361-8388.

Complete your Ccepi 1 form online to ensure timely reporting and compliance with health regulations.