Get Nc Dhhs 3405 2021-2025

The NC DHHS 3405 form is essential for individuals needing a tuberculosis status record. This guide provides clear instructions on how to fill out the form online to ensure accurate and efficient submission.

Follow the steps to complete the NC DHHS 3405 online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide your last name and first name in the designated fields.
3. Fill in the Patient Number and Date of Birth in the format MM/DD/YYYY.
4. Select the appropriate Month, Day, and Year for your date of birth.
5. Indicate your race and respond to whether you identify as Hispanic or Latino.
6. Choose your gender by marking the appropriate box.
7. In Section A, answer each question regarding your health status by selecting ‘Yes’ or ‘No’.
8. If applicable, sign and date the statement to confirm the accuracy of the health statements provided.
9. In Section B, ensure a licensed medical professional completes the necessary details regarding your tuberculin skin test and chest X-ray.
10. After filling in all sections accurately, review the information to ensure it is correct.
11. Save your changes, and you can download, print, or share the completed form as required.

Complete your NC DHHS 3405 online today to ensure your tuberculosis status is accurately documented.