Get the free New Hampshire Confidential STD Reporting Form - dhhs nh

New Hampshire Confidential STD Reporting Form PATIENT INFORMATION Last Name First Name MI DOB // Address City/State/Zip Employer Home Phone Cell Phone Work Phone Sex Male Race White Ethnicity Pregnant - due date // Female Black Hispanic Asian Pacific Islander Not Pregnant Amer Indian/Alaskan Native Marital Status Non-Hispanic Primary language Single Multiracial Other/Unk Married Divorced Please indicate all Sexually Transmitted Disease testing pe...

How to fill out new hampshire confidential std

How to fill out New Hampshire confidential std:

1. Start by obtaining the New Hampshire confidential std form from a healthcare provider or a local health department.
2. Carefully read the instructions provided with the form to ensure that you understand all the required information and any specific guidelines.
3. Begin by filling out your personal information accurately, which may include your name, date of birth, address, phone number, and other relevant details.
4. Provide the necessary information about the healthcare provider who diagnosed or treated you for a sexually transmitted disease (STD). This may include their name, address, and contact information.
5. Indicate the type of STD you were diagnosed with or treated for, and include any specific details that are required on the form.
6. If you were diagnosed with an STD, provide information about when the diagnosis was made and any dates related to treatment or medication.
7. Specify any known sexual contacts that may have been exposed to the same STD, including their names, contact information, and the dates of sexual contact. This information is crucial for contact tracing and preventing further spread of the disease.
8. If there are any additional notes or explanations that need to be included, provide them in the designated section of the form.
9. Review the completed form to ensure that all the necessary information has been provided accurately.
10. Sign and date the form as required, and follow any guidelines for submitting the form, such as mailing it or delivering it to the appropriate healthcare provider or health department.

Who needs New Hampshire confidential std:

1. Individuals who have been diagnosed with a sexually transmitted disease (STD) and are required to report it in the state of New Hampshire.
2. Anyone who has received treatment for an STD in New Hampshire and is requested by their healthcare provider or the health department to fill out the form.
3. Individuals who have had sexual contact with someone diagnosed with an STD and are advised by their healthcare provider or the health department to provide information for contact tracing purposes.

For pdfFiller’s FAQs

What is new hampshire confidential std?

The New Hampshire Confidential STD (Sexually Transmitted Disease) Reporting Form is a confidential reporting system used to gather data on STD cases in New Hampshire.

Who is required to file new hampshire confidential std?

Healthcare providers, laboratories, and other entities involved in the diagnosis or treatment of patients with STDs in New Hampshire are required to file the New Hampshire Confidential STD form.

How to fill out new hampshire confidential std?

To fill out the New Hampshire Confidential STD form, healthcare providers and laboratories need to provide information about the diagnosed STDs, patient demographics, and other relevant details. The form can be accessed and filled out online through the New Hampshire Department of Health and Human Services website.

What is the purpose of new hampshire confidential std?

The purpose of the New Hampshire Confidential STD reporting system is to monitor and track the prevalence of STDs in the state, identify potential outbreaks, and develop targeted prevention and treatment interventions.

What information must be reported on new hampshire confidential std?

The New Hampshire Confidential STD form requires healthcare providers and laboratories to report information such as the type of STD diagnosed, patient demographics (e.g., age, sex), testing and treatment dates, and other relevant clinical and epidemiological data.

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