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Print Form HEPATITIS B PERINATAL PREVENTION CASE REPORT FORM CLIENT INFORMATION Version 1 Last Name First Name Date of Birth (Mo/The/Yr) EDS Number County Mom's Country of Birth Insurance Provider

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What is perinatal hepatitis b imm5?

Perinatal Hepatitis B Imm5 is a form used to report perinatal hepatitis B cases in order to track and prevent the transmission of the virus to newborns.

Who is required to file perinatal hepatitis b imm5?

Healthcare providers, hospitals, and laboratories that diagnose or provide treatment for perinatal hepatitis B cases are required to file the perinatal hepatitis B Imm5 form.

How to fill out perinatal hepatitis b imm5?

The perinatal hepatitis B Imm5 form requires information about the pregnant woman's hepatitis B status, the infant's hepatitis B immunization and testing results, and contact information for the healthcare provider and facility.

What is the purpose of perinatal hepatitis b imm5?

The purpose of the perinatal hepatitis B Imm5 form is to monitor and prevent the transmission of hepatitis B from mother to child during the perinatal period and to ensure proper follow-up care and immunization for infants.

What information must be reported on perinatal hepatitis b imm5?

The perinatal hepatitis B Imm5 form requires reporting of the pregnant woman's hepatitis B surface antigen status, hepatitis B e antigen status, hepatitis B immunoprophylaxis given to the infant, hepatitis B test results for the infant, and contact information for the healthcare provider and facility.

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