Louisiana Department of Health STD Confidential Report Form
This document is used to confidentially report sexually transmitted diseases to the Louisiana Department of Health. It must be filled out accurately for each individual and submitted as per the instructions. It covers various STDs and the treatment administered.
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How do I fill this out?
To fill out this form, provide the requested patient and provider information, including laboratory test results and administered treatments. Ensure accuracy to correctly report the data. Follow the instructions provided for each section of the form.
How to fill out the Louisiana Department of Health STD Confidential Report Form?
1
Fill in the provider information including name, facility, and contact details.
2
Complete the patient information section with all required personal data.
3
Enter the laboratory test details and results for the diagnosed STDs.
4
Specify the treatment administered and the date it was given.
5
Submit the form to the Louisiana Department of Health via mail or fax.
Who needs the Louisiana Department of Health STD Confidential Report Form?
1
Healthcare providers need this form to report diagnosed STDs.
2
Clinics and hospitals use this form to ensure compliance with state reporting requirements.
3
Epidemiologists utilize the data for public health tracking and prevention strategies.
4
State health departments require this form to monitor and control the spread of STDs.
5
Patients' information must be accurately reported by the attending healthcare personnel.
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1
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3
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Download the finalized PDF for submission.
What are the instructions for submitting this form?
Mail or fax the completed form to the Louisiana Department of Health-STD/HIV/Hepatitis Program, PO Box 60630, New Orleans, LA 70160 or FAX to: (504) 568-8384. For additional help, call (504) 568-7474 or visit http://www.LAHHUB.org. Ensure all fields are correctly filled out and the form is submitted promptly after diagnosis.
What are the important dates for this form in 2024 and 2025?
The form needs to be submitted as soon as a diagnosis is made and ideally before treatment is completed.
What is the purpose of this form?
The STD 43 form is essential for reporting newly diagnosed, re-infected, and treated sexually transmitted diseases to the Louisiana Department of Health. Accurate reporting is crucial for the state's public health surveillance, enabling timely intervention and control of STDs. This form ensures compliance with state reporting requirements and aids in the efficient tracking and prevention of STDs.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Information: Includes the name, facility, and contact details of the reporting provider.
- 2. Patient Information: Contains fields for patient personal data such as name, DOB, SSN, and contact information.
- 3. Laboratory Information: Captures details about the laboratory tests conducted and their results.
- 4. Disease Information: Lists the diagnosed STDs and relevant test results.
- 5. Treatment Information: Details the treatment administered including the type, dosage, and date.
What happens if I fail to submit this form?
Failure to submit this form can result in non-compliance with public health reporting laws and hinder the control of STD outbreaks.
- Non-Compliance Penalty: Healthcare providers may face penalties for failing to report as required by state law.
- Spread of STDs: Inaccurate reporting can lead to the uncontrolled spread of STDs in the community.
- Public Health Data Gaps: Incomplete data affects the ability to track and respond to STD trends and outbreaks.
How do I know when to use this form?
- 1. New STD Diagnosis: When a patient is newly diagnosed with an STD.
- 2. Re-Infection: For patients who have been re-infected with an STD.
- 3. Treatment Administered: When treatment for an STD has been given to a patient.
- 4. Public Health Reporting: To comply with state public health reporting requirements.
- 5. Laboratory Confirmation: After receiving positive laboratory test results for an STD.
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What information do I need to fill out this form?
You need to provide provider and patient information, lab test results, and details of the administered treatment.
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What happens if the required fields are incomplete?
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Where do I send the completed form?
The completed form should be sent to the Louisiana Department of Health via the provided mail or fax details.
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