Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin with the required fields at the top of the form. Enter the submitter name and address accurately. Complete the hospital/lab ID number, physician details, and their contact information, including fax and phone numbers.
3. Proceed to the patient information section. Fill in the patient’s name (first, last, and middle initial), gender, and date of birth. Indicate whether the patient is hospitalized.
4. Indicate the symptom onset date if applicable, and select the specimen source from the provided list (e.g., sputum, blood, urine). Make sure to complete the date of collection accurately.
5. Complete the required demographics for the patient, including street address, race, ethnicity, city/town, state, and zip code. Ensure that these details reflect the patient's current residence.
6. If blood lead testing is requested, fill in the additional fields: parent or guardian's name and phone number, and whether the patient has insurance coverage. Include the MaineCare number if necessary.
7. Choose the appropriate tests from the sections on bacteriology, virology, and serology. Clearly mark all tests that are applicable to the patient’s condition.
8. Complete any additional information that might be relevant, such as the MECDC outbreak investigation ID number.
9. After reviewing all entries for accuracy, save your changes. You can then download, print, or share the completed form as required.

Complete your documents online today to ensure timely testing and care.