Health resources services administration 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Reporting State using the appropriate abbreviation. This should reflect the state of the clinician’s office.
3. Fill in the Date of Report, indicating when you completed the form. If applicable, note 'RELAPSE' next to the date for previously reported patients.
4. Provide the Patient Name and Present Address, ensuring to include county and zip code for accurate geographical clustering.
5. Complete fields for Place of Birth, Date of Birth/Sex, and Race/Ethnicity. Remember that race/ethnicity is voluntary.
6. For patients who immigrated, enter the Date Entered the U.S. and provide details on Date of Onset of Symptoms and Date Leprosy First Diagnosed.
7. Indicate how many doctors have been consulted regarding this issue and specify whether the Initial Diagnosis was made in or outside the U.S.
8. Classify Type of Leprosy using ICD-10-CM codes provided on the form, circling specific classifications if possible.
9. List all places where the patient resided before diagnosis under Residence (Pre-diagnosis) and check Yes or No for Disability questions.
10. Finally, document Current Treatment for Leprosy by indicating treatment start date and listing all drugs used.

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