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This document is used by physicians and local health officers to refer HIV positive patients and their contacts to local public health for partner notification assistance, ensuring confidentiality

How to fill out confidential request for local

How to fill out Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services

1. Obtain the Confidential Request form from your local health department or their website.
2. Fill in your personal information, including name, contact details, and address.
3. Provide relevant details about the partner you want to refer, including their name and contact information if known.
4. Specify the reason for the request, explaining the need for counseling and referral services.
5. Check any applicable boxes regarding confidentiality and consent, ensuring the partner's privacy is respected.
6. Review the form for completeness and accuracy before submission.
7. Submit the form to the local health department either in person or via their designated submission method.

Who needs Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

1. Individuals who have been recently diagnosed with a sexually transmitted infection (STI).
2. Those who have a partner requiring guidance or support regarding sexual health.
3. Healthcare providers assisting patients in need of referral services.
4. Public health officials seeking to address STI transmission in the community.

For pdfFiller’s FAQs

What is Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services is a formal request made to local health departments to receive support and resources in conducting partner counseling and referral services, specifically for individuals who have tested positive for certain communicable diseases, ensuring that their partners are informed and provided with necessary health services.

Who is required to file Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

Individuals who have tested positive for certain communicable diseases, healthcare providers, or any authorized representatives of health organizations are typically required to file this request to seek assistance from local health departments.

How to fill out Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

To fill out the request, individuals must provide accurate personal information, details of the communicable disease diagnosis, information about identified partners, and any additional relevant details as required by the local health department's guideline. Follow the provided form instructions carefully to ensure completeness.

What is the purpose of Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

The purpose of the request is to facilitate effective communication and support for individuals who need assistance in notifying their partners about potential exposure to communicable diseases, ensuring that partners have access to the necessary counseling and healthcare referrals.

What information must be reported on Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services?

The information that must be reported includes the individual's name and contact information, details of the disease, names or identifiers of partners, the nature of the relationships, and any relevant medical history that may assist in the referral or counseling process.