Form STD-23 "Sexually Transmitted Diseases Confidential Case Report Form" - Connecticut

What Is Form STD-23?

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

Form Details:

  • Released on May 13, 2016;
  • The latest edition provided by the Connecticut State 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 STD-23 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download Form STD-23 "Sexually Transmitted Diseases Confidential Case Report Form" - Connecticut

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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: www.ct.gov/dph/forms.
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.
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: www.ct.gov/dph/forms.
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.
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Sexually Transmitted Disease
STD CONTROL PROGRAM
Confidential Case Report Form
410 Capitol Avenue, MS#11STD
STD-23
PO Box 340308
(rev. 5/13/2016)
Hartford, CT 06134-0308
Note: Check this box to request forms
PATIENT INFORMATION
PATIENT INFORMATION
Name
(Last)
(First)
(MI)
Date of Birth
Home Phone Number
Other Phone Number
Address
(Number and Street)
(City or Town)
(State)
(Zip Code)
 Male
 Female
 Unknown
 Yes
 No
 Unknown
Marital Status  Married  Single  Unknown
Sex
Pregnant
 White
 Black/African American
 Asian
 Hispanic/Latino
Race
Ethnicity
 Non-Hispanic/Latino
 American Indian/Alaska Native
 Native Hawaiian/Other Pacific Islander
 Unknown
 Other, specify: _______________________________________
 Unknown
 Men
 Women
 Both
 Unknown
 Private
 Medicaid
 None
 Other
Sex of Partners
Insurance Status
DISEASE INFORMATION
DISEASE INFORMATION
 Syphilis
 Gonorrhea
 Chlamydia
 Other STDs
OR
 Primary
 Late Latent – No SX
 Neonatal Herpes
 Symptomatic Uncomplicated
(Chancre Present)
(Duration > 1 Year)
(< 60 days of age)
 Asymptomatic
 Secondary
 Late – With SX
 Chancroid
 Pelvic Inflammatory Disease
(Rash, Lesions, etc.)
 Early Latent – No SX
 Congenital
  Other, specify:_____________________________
(Duration < 1 Year)
PARTNER NOTIFICATION SERVICES
TREATMENT INFORMATION
DIAGNOSTIC INFORMATION
PROVIDER NOTIFICATION SERVICES
TREATMENT INFORMATION
DIAGNOSTIC INFORMATION
Providers treating STDs are expected to counsel patients in
Treatment Date: ____________
Test Date: ______________
prevention and identify and refer partners to medical care for
 Not Treated
 Laboratory Confirmed
examination and treatment.
 Partners referred for exam and treatment by provider.
Specify Antibiotic and Dosage:
 Clinical Diagnosis-No Lab. Confirmation
 Expedited Partner Therapy provided.
_____________________________
Reporting Laboratory: _________________________
 Provider requesting assistance with partner notification
_____________________________
from state health department. Please inform patient of
Results or attach lab report: _____________________
this notification.
_____________________________
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
Name:___________________________ Address:____________________________ Phone Number:__________________ Date Reported:_____________
If reporting from a Hospital or Facility, please complete the following:
Name of person reporting
_________________________________
(if different than above)
Name of Hospital or Facility:________________________  Inpatient
 ER/Urgent Care
 Outpatient Clinic
 OB/GYN
 Family Planning
WHITE (A) – State Health Department
CANARY (B) – Local Health Department
PINK (C) – Submitter’s Copy
DISTRIBUTION -
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