Get the free Lyme Disease Notification Form - Elgin St. Thomas Public Health

Lyme Disease Notification Form **Fax Completed Form to 5196311682** New Report Update Confirmed Reported Date (YYY/MM/DD): Reported By: Hospital Suspect Time: Physician Office School Lab Other Reporting

How to fill out lyme disease notification form

How to fill out lyme disease notification form

1. Obtain a copy of the Lyme disease notification form from the appropriate health department or online.
2. Carefully review the form and make sure you understand all the information required.
3. Fill in your personal details such as name, address, and contact information.
4. Provide details about the healthcare provider who diagnosed you with Lyme disease, including their name, contact information, and license number.
5. Indicate the date of diagnosis and any relevant symptoms or findings associated with Lyme disease.
6. Include information about any treatment you have undergone or are currently undergoing for Lyme disease.
7. If applicable, provide details about any travel history or exposure to ticks in specific areas.
8. Make sure to sign and date the form before submission.
9. Submit the completed form to the designated health department by mail, fax, or online portal.
10. Keep a copy of the form for your records.

Who needs lyme disease notification form?

1. Individuals who have been diagnosed with Lyme disease by a healthcare provider.
2. Healthcare providers who have diagnosed patients with Lyme disease.
3. Health departments and public health agencies that require notification of Lyme disease cases for monitoring and surveillance purposes.

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What is lyme disease notification form?

The lyme disease notification form is a document used to report cases of Lyme disease to the appropriate health authorities.

Who is required to file lyme disease notification form?

Healthcare providers and laboratories are required to file the lyme disease notification form.

How to fill out lyme disease notification form?

The lyme disease notification form can be filled out online or by hand, providing relevant information about the patient and the diagnosis.

What is the purpose of lyme disease notification form?

The purpose of the lyme disease notification form is to track and monitor cases of Lyme disease for public health purposes.

What information must be reported on lyme disease notification form?

Information that must be reported on the lyme disease notification form includes patient demographics, symptoms, test results, and treatment.