Get Cdph 110d

The Cdph 110d form is crucial for reporting COVID-19 cases to local health authorities in California. This guide provides a clear and structured approach to filling out the form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the patient's full name in the designated fields: Last Name, First Name, and Middle Initial. Ensure correct spelling and capitalization of names.
3. Enter the home address details, including the street number, street name, apartment or unit number if applicable, city, state, and ZIP code.
4. Select the ethnicity of the patient by checking the appropriate box: Hispanic/Latino or Non-Hispanic/Non-Latino.
5. Indicate the race of the patient by checking all applicable options.
6. Complete the contact information by adding the home telephone number, cell telephone number, and email address. Also, include the patient's age and date of birth in the specified format (mm/dd/yyyy).
7. Respond to the question regarding pregnancy status by selecting 'Yes' or 'No.' This section is important for understanding any special care needs.
8. Fill out the primary language spoken by the patient and check the relevant boxes under the facility type if applicable, such as skilled nursing facility or hospital-based facility.
9. Complete the hospitalization and diagnostic testing details, including dates and hospitalization status. Ensure that you provide comprehensive answers regarding any previous or current medical conditions.
10. Answer the questions regarding COVID-19 symptoms and any diagnostic testing done. Be thorough in marking all applicable symptoms and test results.
11. If applicable, provide information regarding chronic conditions and any medications taken by the patient. Include drug names, dosages, and routes.
12. Add any additional remarks or details in the section provided to give further context to the report.
13. Once all information is complete and checked for accuracy, you can save changes, download, print, or share the form as needed.

Take the next step towards compliance and submit the Cdph 110d form online today.