Last NameFirst Name. C. Department of Health and Human Services Division of Public Health Epidemiology Section TB ControlMIPatient Number Date of Birth(MM/DD/YYY)Contract Ethnicity: Hispanic or Latino.
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How to fill out the NC DHHS 3405 online
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.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Provide your last name and first name in the designated fields.
- Fill in the Patient Number and Date of Birth in the format MM/DD/YYYY.
- Select the appropriate Month, Day, and Year for your date of birth.
- Indicate your race and respond to whether you identify as Hispanic or Latino.
- Choose your gender by marking the appropriate box.
- In Section A, answer each question regarding your health status by selecting ‘Yes’ or ‘No’.
- If applicable, sign and date the statement to confirm the accuracy of the health statements provided.
- In Section B, ensure a licensed medical professional completes the necessary details regarding your tuberculin skin test and chest X-ray.
- After filling in all sections accurately, review the information to ensure it is correct.
- 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.
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How do I email NC food stamps?
E-mailing us is an efficient and easy way to get the information you need in a timely manner. Request for information or to send general comments please send us an email at dssweb@dhhs.nc.gov. It is our division policy to respond to all email within 5 business days.
How do I contact the NC Department of Health and Human Services?
Administrative Assistance: 919-855-4800 NCDHHS Hotlines. Report Fraud. NC Medicaid. Social Services. Public Health. NC DHSR Complaint Intake Unit. Complaint Hotline: 1-800-624-3004 (within North Carolina) or 919-855-4500. NCDHHS Constituent Services.
How do I contact NC Dhhs?
Contact Details Organization Type:State Medical Assistance Office Organization Description: Medicaid program Covered States and Territories: North Carolina Information: Toll Free: (888) 245-0179 Local: (919) 855-4100 Web Site: https://medicaid.ncdhhs.gov/ Hours: 8:00AM-5:00PM1 more row
How do I contact NC Medicaid customer service?
Customer Service Agents are available to answer questions at this toll-free number: Phone: 800-688-6696. Calls are recorded to improve customer satisfaction.
What is NC Dhhs CST service?
CST is designed to reduce presenting psychiatric or substance abuse symptoms and promote symptom stability, restore the individual's community living and interpersonal skills, provide first responder intervention and deescalate the current crisis, and ensure linkage to community services and resources.
What does NC Dhhs do?
The Department of Health and Human Services manages the delivery of health- and human-related services for all North Carolinians, especially our most vulnerable people – children, elderly, disabled and low-income families.
What are the 4 TB screening questions?
Please answer the following questions: Have you ever had a positive TB skin test? Have you ever had close contact with anyone who was sick with TB? Have you ever been vaccinated with BCG? * The significance of the travel exposure should be discussed with a health care provider and evaluated.
How do I contact DSS in North Carolina?
DSS Customer Connection Child Protective Services 980-31-HELPS (43577) Adult Protective Services 704-336-CARE (2273)
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