Get Department Of State Health Services Confidential Cancer Reporting Form Example 6 - Dshs State Tx

Filling out the Department Of State Health Services Confidential Cancer Reporting Form Example 6 is essential for accurate cancer reporting in Texas. This guide provides step-by-step instructions to ensure users can complete the form online with ease.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Enter the date of admit or first contact using the format YYYYMMDD. For example, if the date is April 7th, 2010, enter 20100407.
3. Fill in the registry number, reporting facility number, and the reporting source. Ensure these numbers are accurate as they are crucial for tracking purposes.
4. Input the medical record number and the class of case. This information identifies the specific case.
5. Enter the individual's last name, first name, and middle name. If applicable, provide the maiden name and any alias names.
6. Complete the address section with the street address, city, state (TX), and zip code. The county code at diagnosis should also be specified.
7. Provide the social security number, date of birth in YYYYMMDD format, and indicate the place of birth.
8. Document race details according to the provided codes and indicate if the individual is of Hispanic origin.
9. Specify the sex of the individual and include employment details such as usual occupation and industry.
10. Fill out the physician follow-up information and sequence number. Ensure all sections related to other primary tumors are completed if applicable.
11. In the treatment section, enter the dates and types of treatments received, including surgery, radiation, chemotherapy, and any other relevant therapeutic treatments.
12. Provide the date of last contact or death, along with the vital status of the individual.
13. Review all filled fields for accuracy. Once all sections have been completed, save changes, then download, print, or share the form as necessary.

Complete your documents online today for accurate and timely cancer reporting.