Follow the steps to accurately complete the KS HIV Perinatal Exposure Report Form.

1. Click ‘Get Form’ button to access the report form and launch it in your document management system.
2. Begin by entering the report date at the top of the form. Next, fill out the reporting facility name to indicate where the report is being generated.
3. In the patient information section, provide the patient's full name including first, last, and maiden names, followed by their apartment/unit number and street address.
4. Continue by filling in the city and zip code, date of birth, phone number, date of pregnancy diagnosis, and estimated delivery date.
5. In the treatment information section, indicate whether the patient is currently on antiretroviral therapy for HIV by selecting 'Yes,' 'No,' or 'Unknown.' Then, enter the HIV diagnosis date.
6. Provide the date of the most recent viral load and the result. Also, include the next scheduled appointment date.
7. Fill in the names and contact numbers for both the OBGYN and Infectious Disease Provider.
8. Check all concerns applicable to the patient, including housing, transportation, nutrition, medication adherence, substance abuse, and mental health. If other issues arise, specify in the provided section.
9. Lastly, ensure you complete the 'completed by' section with your name and phone number and prepare to fax the report to the Kansas Department of Health & Environment.
10. After reviewing all fields for accuracy, you may save changes, download, print, or share the completed form as necessary.

Ensure to complete and submit the KS HIV Perinatal Exposure Report Form online today for timely support and resources.