Get Tx Dshs Nur-0041 2019-2025

The TX DSHS NUR-0041 form is essential for the pre-admission process at the Texas Center for Infectious Disease. This guide provides clear instructions on how to accurately complete the form online, ensuring that all necessary information is provided.

Follow the steps to fill out the TX DSHS NUR-0041 form online:

1. Press the ‘Get Form’ button to retrieve the TX DSHS NUR-0041 form and open it in your preferred document editor.
2. Begin by filling out Part I: Patient Information. Enter the patient's last name, first name, age, gender, date of birth (DOB), complete address, city, middle initial (MI), Social Security number (SSN), county, and zip code. Indicate if the patient is homeless and provide a contact phone number. Fill in the race, ethnicity, and language spoken.
3. Next, provide the place of birth, citizenship status, and country of origin. Document the marital status, employment status, and religion. Specify any guardianship details and advanced directives, including Do Not Resuscitate (DNR) status.
4. List any power of attorney details, and note if there is a court order in place. Enter any known allergies and insurance details, selecting from options like Medicare, Medicaid, or Uninsured.
5. For Insurance, enter the policy number and complete the emergency contact/next of kin section with their last name, first name, address, phone number, city, MI, state, zip code, and relationship.
6. Proceed to Part II: Referring Provider. Indicate the referral region, Local Health Department, and name of the hospital if transferring. Fill in the physician's name, referring agency, case manager's information, including fax number, phone number, and email.
7. In Part III: Tuberculosis, document the indication for admission and complete the necessary tests for TB, providing results for sputum/AFB culture, NAAT, PCR, imaging results, and additional tests.
8. Continue with documenting current medications, dates started, and any refused TB medication doses. Provide details on any prior treatment for TB and any adverse reactions experienced.
9. Complete Part IV: Other Conditions by indicating HIV status, viral load dates, medical history, and any assistive devices used. Check relevant conditions and provide additional information on functional capacity.
10. In Part V: Records Included, list all relevant medical records that are being submitted along with the form.
11. Finish by completing Part VI: Additional Information, followed by sections intended for TCID use only, including admission approval, attending physician details, and transport arrangements.
12. Once you have completed all sections of the form, ensure all information is accurate. You may then save changes, download, print, or share the completed form as needed.

Start filling out the TX DSHS NUR-0041 form online today to ensure timely processing.