"New Mexico Occupational Health Registry Confidential Case Report" - New Mexico

This fillable "New Mexico Occupational Health Registry Confidential Case Report" is a document issued by the New Mexico Department of Health specifically for New Mexico residents.

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Download "New Mexico Occupational Health Registry Confidential Case Report" - New Mexico

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New Mexico Occupational Health Registry Confidential Case Report
When completed, please fax this form to NMOHR at (505) 827-0013
Name of person completing form:
Date completed:
Demographic information
Name of ill or injured person (last name, first name, middle name)
DOB
Gender:
M
F
Unk.
(mm/dd/yyyy)
Address at time of visit (Street)
Race/ethnicity
White
Am. Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
City
County
State
Zip
Other
Unknown
Home Phone
May we contact?
Social Security Number
Hispanic ethnicity
NM Tribal Code
Y
N
Y
N
Age
Job status
Insured? Y
N
Payer
Patient’s visit and condition
Referred by
Date of visit
Date of diagnosis
Patient’s complaint
Diagnosis / ICD9
Exposure(s) related to diagnosis
Comment
Conditions – as per New Mexico Administrative Code 7.4.3.11
Asbestosis
Occupational burn hospitalization
Coal worker’s pneumoconiosis
Occupational injury death
Hypersensitivity pneumonitis
Occupational pesticide poisoning
Mesothelioma
Occupational traumatic amputation
Noise induced hearing loss
Silicosis
Occupational asthma
Other illness or injury related to occupational exposure
Occupation information (please complete for employment at time of suspected exposure)
Job title
Industry type
Name of company
Company address (Street)
City
State
Zip
Phone
Exposure/incident date or
Exposure end
start date
date
Other employers/exposures (include dates)
Reporting healthcare provider/healthcare facility/laboratory information
Name of physician
Physician specialty
Physician’s phone
Address (Street)
City
State
Zip
Name of facility/laboratory
Phone number
Contact person
Address (Street)
City
State
Zip
New Mexico Occupational Health Surveillance Program, NM Department of Health
1190 St. Francis Drive, N1320 * Santa Fe, New Mexico * 87502
(505) 476.3530
New Mexico Occupational Health Registry Confidential Case Report
When completed, please fax this form to NMOHR at (505) 827-0013
Name of person completing form:
Date completed:
Demographic information
Name of ill or injured person (last name, first name, middle name)
DOB
Gender:
M
F
Unk.
(mm/dd/yyyy)
Address at time of visit (Street)
Race/ethnicity
White
Am. Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
City
County
State
Zip
Other
Unknown
Home Phone
May we contact?
Social Security Number
Hispanic ethnicity
NM Tribal Code
Y
N
Y
N
Age
Job status
Insured? Y
N
Payer
Patient’s visit and condition
Referred by
Date of visit
Date of diagnosis
Patient’s complaint
Diagnosis / ICD9
Exposure(s) related to diagnosis
Comment
Conditions – as per New Mexico Administrative Code 7.4.3.11
Asbestosis
Occupational burn hospitalization
Coal worker’s pneumoconiosis
Occupational injury death
Hypersensitivity pneumonitis
Occupational pesticide poisoning
Mesothelioma
Occupational traumatic amputation
Noise induced hearing loss
Silicosis
Occupational asthma
Other illness or injury related to occupational exposure
Occupation information (please complete for employment at time of suspected exposure)
Job title
Industry type
Name of company
Company address (Street)
City
State
Zip
Phone
Exposure/incident date or
Exposure end
start date
date
Other employers/exposures (include dates)
Reporting healthcare provider/healthcare facility/laboratory information
Name of physician
Physician specialty
Physician’s phone
Address (Street)
City
State
Zip
Name of facility/laboratory
Phone number
Contact person
Address (Street)
City
State
Zip
New Mexico Occupational Health Surveillance Program, NM Department of Health
1190 St. Francis Drive, N1320 * Santa Fe, New Mexico * 87502
(505) 476.3530
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