Get Nc Dhhs 5010 2022-2026

The NC DHHS 5010 form is essential for the submission of laboratory specimens to the North Carolina Department of Health and Human Services. This guide provides step-by-step instructions to help users fill out the form online with ease and accuracy.

Follow the steps to fill out the NC DHHS 5010 form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the 'Personal Information' section by entering your last name, first name, middle initial, and maiden name/surname. Ensure all fields are filled accurately.
3. Provide your address details in the designated fields, including street address, city, state, and zip code. Include any additional address information if applicable.
4. Enter your insurance ID number if applicable, along with your county code.
5. Fill in your medical record number and phone number. Provide your Medicaid number if it's relevant.
6. In the 'Date of Birth' field, enter your date of birth. Select your sex from the options provided, ensuring to mark the correct choice.
7. Choose your race by marking all applicable options and indicate your ethnicity by selecting one of the provided choices.
8. Fill out the 'Submitter Information' section with your name, address, and contact details including email and phone number.
9. Enter the ordering provider’s NPI and their first and last name. Add the contact name and contact phone number.
10. Specify the collection date and time, ensuring to format it correctly. Indicate the reason for testing using the ICD-10 diagnosis code.
11. Select the specimen type by marking the applicable box and provide further details if necessary.
12. Indicate the specimen source by marking the relevant boxes.
13. Complete the sections for clinical and epidemiological information, any associated illnesses, pertinent clinical or lab findings, as well as travel details.
14. After filling out the form, you can save changes, download, print, or share the form as needed.

Complete your NC DHHS 5010 form online today for efficient submission.