Instructions for "Tuberculosis (Tb) Treatment and Follow-Up Care Report Form" - Connecticut

This document was released by Connecticut State Department of Public Health and contains the most recent official instructions for Tuberculosis (Tb) Treatment and Follow-Up Care Report Form.

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INSTRUCTIONS FOR SUBMITTING
TUBERCULOSIS (TB) TREATMENT AND FOLLOW-UP CARE REPORT FORM
Revised January 2017
NEW: The Department of Public Health has revised and renamed the former TB-32 form. It is
now called the Tuberculosis Treatment and Follow-Up Care Report Form.
WHEN TO REPORT:
This one-page form should be completed each time a TB patient is medically evaluated
while on treatment for TB disease or latent TB infection (LTBI) and submitted to the
DPH TB Control Program and the local health department where the patient resides.
WHY REPORT SUPERVISION OF PATIENTS?
*
Documents your recommended monthly supervision of the patient.
*
Coordinates and documents outreach and directly observed therapy (DOT).
*
Validates office visits for payment by DPH TB Control Program.
WHAT SHOULD BE REPORTED?
*
Medication changes (MUST BE ACCOMPANIED BY A NEW PRESCRIPTION).
*
Continuing ingestion, reaction to or completion of medication.
*
Sputum conversion.
*
Comparative x-rays.
*
Patient address changes.
*
Other information not known at time of original report.
IMPORTANT!!!! For patients on treatment for TB disease, notify both the DPH TB Control
Program and the local health department where the patient resides when a patient:
*
Refuses care.
*
Misses clinic appointments.
*
Become non-adherent with medications.
Medical consultation is available for all TB-related treatment questions through the DPH TB Control
Program.
Completed forms may be faxed or mailed (in an envelope marked “Confidential”) to:
DPH Tuberculosis Control Program
410 Capitol Ave. MS#11TUB
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 509-7743
All forms are also available on the Department of Public Health website at
http://www.ct.gov/dph/forms.
A limited number of paper forms can be requested by phone at (860) 509-7722.
INSTRUCTIONS FOR SUBMITTING
TUBERCULOSIS (TB) TREATMENT AND FOLLOW-UP CARE REPORT FORM
Revised January 2017
NEW: The Department of Public Health has revised and renamed the former TB-32 form. It is
now called the Tuberculosis Treatment and Follow-Up Care Report Form.
WHEN TO REPORT:
This one-page form should be completed each time a TB patient is medically evaluated
while on treatment for TB disease or latent TB infection (LTBI) and submitted to the
DPH TB Control Program and the local health department where the patient resides.
WHY REPORT SUPERVISION OF PATIENTS?
*
Documents your recommended monthly supervision of the patient.
*
Coordinates and documents outreach and directly observed therapy (DOT).
*
Validates office visits for payment by DPH TB Control Program.
WHAT SHOULD BE REPORTED?
*
Medication changes (MUST BE ACCOMPANIED BY A NEW PRESCRIPTION).
*
Continuing ingestion, reaction to or completion of medication.
*
Sputum conversion.
*
Comparative x-rays.
*
Patient address changes.
*
Other information not known at time of original report.
IMPORTANT!!!! For patients on treatment for TB disease, notify both the DPH TB Control
Program and the local health department where the patient resides when a patient:
*
Refuses care.
*
Misses clinic appointments.
*
Become non-adherent with medications.
Medical consultation is available for all TB-related treatment questions through the DPH TB Control
Program.
Completed forms may be faxed or mailed (in an envelope marked “Confidential”) to:
DPH Tuberculosis Control Program
410 Capitol Ave. MS#11TUB
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 509-7743
All forms are also available on the Department of Public Health website at
http://www.ct.gov/dph/forms.
A limited number of paper forms can be requested by phone at (860) 509-7722.