To submit the form, email it directly to the designated health department email provided. You may also fax it to the number listed at the bottom of the form. Alternatively, physical submissions can be made at the address specified in the document. Always ensure your submission includes any necessary specimens and certifications.

Key dates to remember include annual program updates in January and the start of public health initiatives each April. Ensure timely submissions for all relevant testing periods. Review form details annually for compliance and updates.

The purpose of this form is to efficiently gather and submit patient information for HIV and STD testing. It ensures compliance with public health guidelines and facilitates accurate record-keeping. This form is crucial for maintaining health standards and providing necessary screenings in the community.

• 1. Patient Name: Full name of the patient, formatted as Last, First.
• 2. Date of Birth: Patient's date of birth in mm/dd/yyyy format.
• 3. Requesting Physician: Name of the physician requesting the test.
• 4. Test Type: Type of test being requested, such as HIV1/2 screening.
• 5. Specimen Source: Indicates where the specimen will be collected from.

Failing to submit this form may lead to delays in testing and results. It is important to adhere to the proper submission protocols to ensure timely processing.

• Delay in Testing: Without submission, necessary testing cannot commence.
• Inaccurate Records: Missing information can lead to discrepancies in health records.
• Compliance Issues: Failure to submit on time may violate public health mandates.

• 1. Routine Testing: Utilize this form for regular health screenings.
• 2. Public Health Programs: Essential for documenting participation in public health initiatives.
• 3. Patient Referrals: Required when referring patients for specialized testing.