Get Ia Treatment Of Latent Tuberculosis Infection (ltbi) Medication Request Form 2020-2025

Filling out the IA Treatment Of Latent Tuberculosis Infection (LTBI) Medication Request Form online can facilitate timely treatment for individuals diagnosed with LTBI. This guide offers clear instructions to ensure users can complete this essential form with confidence.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your demographics in the designated fields, including your name (last, first), date of birth (MM/DD/YYYY), weight, street address, city, zip code, county of residence, gender, phone number, and any medication allergies you may have.
3. Indicate if you are pregnant and if an interpreter is required, specifying the language if necessary.
4. Fill in the diagnostics section by providing the date and results of your Tuberculin skin test and IGRA (blood) test if applicable. Include the chest X-ray date and ensure to submit the radiology report which should be dated within three months of this request.
5. Confirm your LTBI diagnosis by checking 'Yes' or 'No.' Additionally, confirm if pulmonary TB disease has been ruled out and provide details if any extra pulmonary TB disease has also been ruled out.
6. Select the preferred regimen for the treatment of LTBI according to the 2020 CDC/NTCA guidelines by checking the box or writing a prescription based on the patient’s weight.
7. Sign the form in the designated area for clinician signature, and provide the clinician’s name, clinic name, street address, city, phone number, and fax number.
8. Specify where the medication should be sent by choosing from the options provided (County Public Health Department, Clinician’s Office, or Other).
9. Review the checklist to ensure the patient is aware of their LTBI diagnosis and treatment plan, ensure the radiology report is attached, confirm the clinician's signature, and if the form is unsigned, note that a separate prescription is required.
10. Fax this completed form along with the X-ray report and prescriptions to the specified number: 515-281-4570.

Ensure timely access to treatment by completing the IA Treatment Of Latent Tuberculosis Infection (LTBI) Medication Request Form online today.