Get Lost To Hearing Follow-up Report - State Nj

This guide provides clear and supportive instructions for filling out the Lost to Hearing Follow-Up Report for New Jersey. It is designed to help users navigate the form with ease and ensure all necessary information is completed accurately.

Follow the steps to successfully complete the report online.

1. Click ‘Get Form’ button to begin the process of obtaining the Lost to Hearing Follow-Up Report. This will allow you to access the document and fill it out seamlessly.
2. Start by entering the baby's name in the format of Last, First, followed by the date of birth and medical record number. Ensure all identifiers are accurate to match outpatient results with inpatient screening status.
3. Fill in the sex of the baby by selecting either Male or Female. Then, provide the full name of the parent or guardian along with their relationship to the child.
4. Input the physician's name and contact information, including the telephone number, street address, and zip code. Ensure all details are correct to facilitate communication.
5. Select the facility of birth and indicate the reason testing was required by checking the appropriate box(es). If a specific reason is not listed, feel free to write it in the 'Other' field.
6. Document the date when the child was declared lost to or discharged from follow-up. This can be the date of a missed appointment or other outreach failure.
7. In the 'Lost to Follow Up' section, check all applicable boxes to indicate any communication attempts made with the family. Include the dates of these attempts for record-keeping purposes.
8. If applicable, outline the reasons for discharging from continued follow-up care in the designated section. Make sure to detail the circumstances clearly.
9. Complete the form by providing your name, title, telephone number, and the facility name and address where the report is being submitted.
10. Once all fields are filled out, review the information for accuracy. You can then save your changes, download the report, print it, or share it as needed.

Take prompt action by completing the Lost to Hearing Follow-Up Report online today.