Get Als Case Reporting Form - Nj

The ALS Case Reporting Form - Nj is essential for documenting cases of amyotrophic lateral sclerosis (ALS) in accordance with established medical criteria. This guide provides a detailed overview of how to accurately complete the form online, ensuring all necessary information is provided efficiently.

Follow the steps to fill out the ALS Case Reporting Form - Nj online.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the date completed in the designated field, using the format __/__/. Fill in the name of the person completing the form along with their job title and name of the practice.
3. Provide the phone number in the specified format (___) ___-____.
4. In the demographic information section, indicate race by checking all applicable boxes, and provide details about the ethnicity.
5. Fill in the country of birth in the appropriate field.
6. For the diagnosis information, select the El Escorial Criteria as determined by an ALS specialist, ensuring you check the correct classification.
7. Record the date of diagnosis and the date of onset of symptoms using the specified formats for both fields.
8. Provide the name of the provider making the report, including last name, first name, middle name or initial, and suffix.
9. Complete the address section with the number, street, city, state, and zip code.
10. Include the last five digits of the Social Security number and the date of birth in the required format.
11. Select the sex of the individual from the provided options.
12. Answer the questions related to dementia diagnosis, family history of ALS, and payer type by checking the relevant boxes.
13. Once all sections are filled, review the form for accuracy. You may then save changes, download, print, or share the form as needed.

Complete the ALS Case Reporting Form - Nj online today to ensure accurate documentation and reporting of ALS cases.