Form Std-23 - Sexually Transmitted Diseases Form- Confidential Case Report - Connecticut

Download a blank fillable Form Std-23 - Sexually Transmitted Diseases Form- Confidential Case Report - Connecticut in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Std-23 - Sexually Transmitted Diseases Form- Confidential Case Report - Connecticut with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Sexually Transmitted Disease
State of Connecticut
Confidential Case Report Form
Department of Public Health
STD-23
(rev. 5/13/2016)
List of Reportable Sexually Transmitted Diseases
Chancroid
Chlamydia
Gonorrhea
Neonatal herpes (< 60 days of age)
Syphilis
INSTRUCTIONS FOR SUBMITTING STD-23:
This form is for reporting sexually transmitted diseases as required under Connecticut General Statute 19a-215, and Public Health Codes 19a-36-A2
through 19a-36-A4.
If appropriate treatment has been provided, please complete the “Treatment Information” section of this form.
STDs are considered category 2 diseases. This report must be completed and mailed in an envelope marked “CONFIDENTIAL” within 12 hours of
recognition or strong suspicion of disease to:
1. Local Director of Health of
(Canary)
AND
2. State of Connecticut
(White)
town in which patient resides.
Department of Public Health
410 Capitol Avenue, MS#11STD
P.O. Box 340308
Hartford, CT 06134-0308
If OUT OF STATE RESIDENT, submit both copies to the Department of Public Health (DPH) STD Control Program.
STD Supportive Services
Forms may also be completed and FAXed to our office:
(860) 509-7275
Diagnostic, Treatment and Epidemiologic Consultation, Patient Referral
AND
Assistance, Partner Services, Professional Medical Reference and Resource
to the Local Health Department of the Patient’s Residence.
Materials may be obtained by calling the DPH STD Control Program at:
The STD-23 and other reportable disease forms are available on our
(860) 509-7920
website:
Health Insurance Portability and Accountability Act (HIPAA) Guidelines
Pursuant to Connecticut General Statutes (CGS) § 19a-2a and § 19a-215, and to the Regulations of Connecticut State Agencies §s 19a-36-A3-4, the requested
information is required to be provided to the DPH.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2