New Hampshire providers report HIV infection or AIDS in patients older than 13 on this two-page case report form (ACRF_03_2022), as RSA 141-C and He-P 300 require. The form gathers diagnostic status, demographics, risk history, laboratory data, AIDS indicator diseases, treatment and referral details, and pregnancy information for the state HIV/AIDS Surveillance Program.
The current provider, or the person completing it for the facility, fills in the form except Section I, which is for HIV/AIDS Surveillance Program use only. Patient identifier information in Section II is not transmitted to CDC.
Download the current version from the source each time; forms change without notice.
New Hampshire Adult HIV/AIDS Case Report Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form asks whether the patient has been informed of the infection and who will notify partners about their HIV exposure and counsel them: the health department, the medical provider, the patient, or unknown. It also records how the patient's medical treatment is primarily reimbursed, such as Medicaid/Medicare or private insurance.
Yes. The DHHS reporting page tells providers to fax reports, including HIV/AIDS, to the Bureau of Infectious Disease Control, and this form prints the same fax line. The older 2017 General Disease Reporting Form still says not to fax HIV reports, but HIV has its own form.
The facility of diagnosis, with physician, address and facility type (private physician, emergency room, counseling and testing site, hospital inpatient or outpatient, OB/GYN, health department, STD clinic, corrections or other), plus the current provider's name, facility, phone and medical record number.