Form NHSP100-1 "Infant Reporting Form - Region a/B" - California

What Is Form NHSP100-1?

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

Form Details:

  • The latest edition provided by the California Department of Health Care Services;
  • 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 NHSP100-1 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form NHSP100-1 "Infant Reporting Form - Region a/B" - California

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Screening
N E W B O R N H E A R I N G S C R E E N I N G
I n f a n t
R e p o r t i n g
F o r m
I
( I P ) S
C
N PA T I EN T
C R E E N
O M P L E T E D
IP
R I G H T
L E F T
E A R
E A R
DATE
S
OF
CREENING
ABR
ABR
ABR
ABR
TYPE
S
OF
CREENIN
G
DPOAE
DPOAE
DPOAE
DPOAE
(check one)
TEOAE
TEOAE
TEOAE
TEOAE
PASS
PASS
PASS
PASS
RESULT
(check one)
REFER
REFER
REFER
REFER
ABR-Auditory Brainstem Response
DPOAE-Distortion Product Otoacoustic Emission
TEOAE-Transient Evoked Otoacoustic Emission
I N P A T I E N T
S C R E E N
N O T D O N E
Transferred out to (Hospital Name)
(Unit)
on (date):
Missed; discharged without screen (Complete Follow-Up section below)
Wai
ved (
Face Sheet not required)
­
NHSP Brochure given to parent
Expired or
Not medically indicated for screening per physician determination (Face Sheet not required)
Baby has Atresia
Bilateral or
Unilateral (check one):
Right
Left
Early Start Referral made
Microtia
Bilateral or
Unilateral (check one):
Right
Left
(Complete Follow-Up section below)
F
- U
R
/ M
O L L OW
P F O R
E F E R S
I S S E D
Parent/Legal Guardian information on face sheet verified/updated
:
Primary Language
English
Spanish
Other:
(Check One)
Mother’s Race:
Mother’s Ethnicity:
Mother’s Education:
Secondary contact information (relative or friend)
Relationship
Name: (Other than Parent):
Cell Phone (
Home Phone: (
Work Phone (
)
)
)
Address:
City/Zip:
:
English
Spa s
ni h
Other:
Primary Language
(Check One)
Print Infant’s Full/Legal Name:
NHSP Brochure given to parent (check one):
Refer
Refer to D
X
Follow-Up Appointment made and written on parent brochure:
APPOINTMENT:
OP SCREENING
DX EVALUATION for Atresia or Microtia OR per Physician Determination
CA Children’s Services (CCS) Referral Made–County:
DATE:
TIME:
(
)
PROVIDER:
Phone:
Phone: (
)
PCP
who will see the Infant after discharge – Na
me:
Completed form faxed with hospital face sheet to the Northern California Hearing Coordination Center,
Fax No. (800) 866-1074. HCC contact phone No. (800) 645-3616, press #3.
Medical Record Number:
Patient Name:
Submitting Hospital Name:
Birth
Date:
Gender: Male
Female
† WBN † NICU Gest. Age @ birth:
wks
Birth Hospital
NHSP 100-1 Region A/B
Screening
N E W B O R N H E A R I N G S C R E E N I N G
I n f a n t
R e p o r t i n g
F o r m
I
( I P ) S
C
N PA T I EN T
C R E E N
O M P L E T E D
IP
R I G H T
L E F T
E A R
E A R
DATE
S
OF
CREENING
ABR
ABR
ABR
ABR
TYPE
S
OF
CREENIN
G
DPOAE
DPOAE
DPOAE
DPOAE
(check one)
TEOAE
TEOAE
TEOAE
TEOAE
PASS
PASS
PASS
PASS
RESULT
(check one)
REFER
REFER
REFER
REFER
ABR-Auditory Brainstem Response
DPOAE-Distortion Product Otoacoustic Emission
TEOAE-Transient Evoked Otoacoustic Emission
I N P A T I E N T
S C R E E N
N O T D O N E
Transferred out to (Hospital Name)
(Unit)
on (date):
Missed; discharged without screen (Complete Follow-Up section below)
Wai
ved (
Face Sheet not required)
­
NHSP Brochure given to parent
Expired or
Not medically indicated for screening per physician determination (Face Sheet not required)
Baby has Atresia
Bilateral or
Unilateral (check one):
Right
Left
Early Start Referral made
Microtia
Bilateral or
Unilateral (check one):
Right
Left
(Complete Follow-Up section below)
F
- U
R
/ M
O L L OW
P F O R
E F E R S
I S S E D
Parent/Legal Guardian information on face sheet verified/updated
:
Primary Language
English
Spanish
Other:
(Check One)
Mother’s Race:
Mother’s Ethnicity:
Mother’s Education:
Secondary contact information (relative or friend)
Relationship
Name: (Other than Parent):
Cell Phone (
Home Phone: (
Work Phone (
)
)
)
Address:
City/Zip:
:
English
Spa s
ni h
Other:
Primary Language
(Check One)
Print Infant’s Full/Legal Name:
NHSP Brochure given to parent (check one):
Refer
Refer to D
X
Follow-Up Appointment made and written on parent brochure:
APPOINTMENT:
OP SCREENING
DX EVALUATION for Atresia or Microtia OR per Physician Determination
CA Children’s Services (CCS) Referral Made–County:
DATE:
TIME:
(
)
PROVIDER:
Phone:
Phone: (
)
PCP
who will see the Infant after discharge – Na
me:
Completed form faxed with hospital face sheet to the Northern California Hearing Coordination Center,
Fax No. (800) 866-1074. HCC contact phone No. (800) 645-3616, press #3.
Medical Record Number:
Patient Name:
Submitting Hospital Name:
Birth
Date:
Gender: Male
Female
† WBN † NICU Gest. Age @ birth:
wks
Birth Hospital
NHSP 100-1 Region A/B