Follow the steps to fill out the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by entering the patient information in the designated fields. Include the patient's name, last four digits of their Social Security Number, street address, medical record number, date of birth, age, city, state, zip code, provider phone number, provider fax number, city, state, procedure, and the final diagnosis.
3. Next, fill out the provider information section. This includes the provider's name, practice name, street address, and zip code.
4. Move to the cervical pathology section. Here, document the specimen collection date and the pathology lab name.
5. In the patient race and insurance information section, check all applicable boxes to indicate the patient's race and ethnicity. Also, select all applicable insurance options.
6. For HPV vaccine history, indicate if the patient's vaccination status is documented. If yes, specify if the patient has received the vaccine and number of doses. Provide the dates of each dose and the administering office's information.
7. In the PAP and HPV testing history section, indicate if a Pap test was done and provide the details including the date and results. Similarly, document the HPV test information.
8. Lastly, answer whether the patient is immunocompromised for any reason. Ensure all fields are completed as required.
9. After filling out the form, review your entries for accuracy, then save your changes, and explore options to download, print, or share the filled form.

Begin completing your Case Report Form Sample online to ensure timely and accurate submission.