Get Chlaymdia/gonorrhea Detection (dhhs 4011)

Filling out the Chlamydia/Gonorrhea Detection (DHHS 4011) form online is a straightforward process that ensures accurate submissions for testing. This guide will walk you through each section of the form, making it easy to provide the necessary information.

Follow the steps to complete your form efficiently

1. Click ‘Get Form’ button to obtain the form and access it in the online editor.
2. Provide your last name, first name, and middle initial in the respective fields. If applicable, include your maiden name or surname.
3. Fill in your address information, including street address, city, state, zip code, and county name. If needed, you can also add an additional address line.
4. Enter your phone number and, if applicable, your Medicaid number.
5. Input your date of birth in the designated format and select your sex from the options provided: Male, Female, Unknown, or Ambiguous.
6. For race, mark all categories that apply to you.
7. If applicable, indicate your pregnancy status and your ethnicity by selecting the appropriate options.
8. Specify the clinic or program type you are associated with.
9. Provide the ordering provider's information, including NPI, first and last name, and contact details.
10. Complete the specimen section by including the collection date and the test ordered: Chlamydia/Gonorrhea Detection.
11. Select the specimen source from the options: Vaginal, Urine, Rectal, or Oropharyngeal.
12. Fill out the reason for testing by specifying the ICD-10 diagnosis code and marking the appropriate reason for testing.
13. Review all provided information for accuracy.

Start completing the Chlamydia/Gonorrhea Detection form online today.