TN Syphilis History Request

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Tennessee Syphilis History Request

Licensed health care providers can access current and historical syphilis test results and treatment information for patients who are Tennessee residents to inform the diagnosis and management of syphilis in their patients. Clinical consultation is available at the National Network of STD Clinical Prevention Training Centers clinical consult network NNPTC Online Consultation .

The Tennessee Department of Health (TDH) maintains records of positive syphilis test results for Tennessee residents. Clinical laboratories (laboratory instructions) and healthcare providers (healthcare provider instructions) are required by law (T.C.A. §68 Rule 1200-14-01-.02) to report all positive syphilis test results for Tennessee residents. Additional information on reportable disease in Tennessee is available at this link .

Instructions:

Complete the following survey
A Tennessee Department of Health employee will call the office/facility phone number to confirm that the individual is a current patient; once confirmed, the staff member will call the requesting provider preferred phone
Test results and treatment history will be provided verbally then securely emailed to the requesting healthcare provider
If no results are found, a secure email will be sent to the requesting healthcare provider
Institutional firewalls occasionally block receipt of emails. If you do not receive a response in the expected timeframe, please call 615-741-7500 and ask to speak with Rebecca Moore or Lavonne Cole

Date

M-D-Y

Facility Information

Facility or Practice Name:

* must provide value

Facility Address:

* must provide value

Facility City:

* must provide value

Facility State:

* must provide value

Facility Zipcode:

* must provide value

Practice or facility direct phone number to confirm patient's relationship to requesting provider:

* must provide value

TDH STAFF ONLY

Confirmed via web search or other means that phone number is affiliated with that facility.

Yes

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Confirmed with practice/facility that patient is affiliated with requesting provider.

Yes

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Record Found?

Yes

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Provider Information

Requesting Clinician:

* must provide value

Requesting Clinician Tennessee License Number:

* must provide value

Requesting Clinician National Provider Identifier:

* must provide value

Clinician Direct Phone Number:

* must provide value

Clinician Business Email:

* must provide value

TDH STAFF ONLY

Confirmed provide license number and NPI?

Yes

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Reached provider by phone, confirmed:

patient name
date of birth

Provided necessary information verbally.

Yes

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Confirmed email address provided is correct?

Yes

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Patient Information

Patient First Name:

* must provide value

Middle Initial (if available):

Patient Last Name:

* must provide value

Date of Birth:

* must provide value

M-D-Y

Age:

* must provide value

View equation

Last 4 Digits of Social Security #:

Street Address:

* must provide value

City:

* must provide value

State:

* must provide value

Zipcode:

* must provide value

Phone Number:

* must provide value

TDH STAFF ONLY

PRISM ID#:

* must provide value

Provider requesting a PDF copy of results?

Yes

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COMPLETE AFTER PROVIDER EMAIL CONFIRMED

Tennessee Syphilis History Request

Attachment:Tennessee Syphilis History Request..pdf

Upload completed Syphilis History Request here:

Upload file

Securely email uploaded pdf with available lab results and treatment information to requesting provider, cc'ing Syphilis.History@tn.gov?

Yes

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TDH Notes on this request:

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