Form CDPH9040 "Out-Of-State Syphilis Record Search Request Form" - California

What Is Form CDPH9040?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH9040 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH9040 "Out-Of-State Syphilis Record Search Request Form" - California

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State of California-Health and Human Services Agency
California Department of Public Health
OUT-OF-STATE SYPHILIS RECORD SEARCH REQUEST FORM
TO: CDPH STDCB ICCR
FROM: ______________________
FAX: 916-636-6212
Fax: _____________________
Phone: ___________________
Date: __________________
RECORD SEARCH DETAILS:
Please complete as much information as possible
Name of Client: ___________________________________________________
AKA (s):
________________________________________________________
DOB or Age: _____________________________________________________
If Previous HX Claimed by Client, Please Provide the Following:
Provider/Facility
: ________________________________________________________________
Medical Record Number
: ________________________________________________________
Date of Visit/Year
: _______________________________________________________________
City/State
: _______________________________________________________________________
Other Pertinent Info
: Need any Syphilis information: labs, treatments, and diagnosis
CDPH 9040 (4/18)
State of California-Health and Human Services Agency
California Department of Public Health
OUT-OF-STATE SYPHILIS RECORD SEARCH REQUEST FORM
TO: CDPH STDCB ICCR
FROM: ______________________
FAX: 916-636-6212
Fax: _____________________
Phone: ___________________
Date: __________________
RECORD SEARCH DETAILS:
Please complete as much information as possible
Name of Client: ___________________________________________________
AKA (s):
________________________________________________________
DOB or Age: _____________________________________________________
If Previous HX Claimed by Client, Please Provide the Following:
Provider/Facility
: ________________________________________________________________
Medical Record Number
: ________________________________________________________
Date of Visit/Year
: _______________________________________________________________
City/State
: _______________________________________________________________________
Other Pertinent Info
: Need any Syphilis information: labs, treatments, and diagnosis
CDPH 9040 (4/18)