Get Example Pg Number - Dshs State Tx

The Example Pg Number - Dshs State Tx is a critical document used for reporting cancer cases in Texas. Completing this form accurately is essential for proper reporting and follow-up care.

Follow the steps to complete the cancer reporting form effectively.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by filling in your date of admission or first contact in the MMDDYYYY format. This section is typically labeled as ‘DATE OF ADMIT/FIRST CONTACT’.
3. Next, provide the registry number assigned to the case. This will be in a field titled ‘REGISTRY NUMBER’.
4. Indicate the reporting facility number in the section named ‘REPORTING FACILITY NUMBER’. Be sure that this number corresponds with the facility where the diagnosis was made.
5. Complete the ‘REPORTING SOURCE’ field, detailing how the information was reported.
6. Enter the medical record number in the ‘MEDICAL RECORD #’ section, ensuring it is accurate and corresponds to the patient's records.
7. Identify the class of case in the section labeled ‘CLASS OF CASE’. This field helps categorize the type of cancer being reported.
8. Fill out the personal identifying details, including the last name, first name, middle name, maiden name, and any alias name if applicable.
9. Provide the street address and city information, ensuring that the inputs are clear and precise.
10. Select the state and fill in the ZIP code in their respective fields.
11. Continue filling out the physician information, including the managing physician and follow-up physician in the designated sections.
12. Input the primary payer at diagnosis information, date of initial diagnosis, and include any additional fields as required by the specific case.
13. Review the additional medical information fields, including previous tumor information and any demographic data requested.
14. After completing all required fields, summarize the treatment details and clinical information as specified.
15. Once all data is entered, review your information for accuracy and save changes. You may then opt to download, print, or share the completed form as needed.

Complete your cancer reporting form online today for efficient processing.