The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

eaN5vFW2vuHbfub2NtMttpLpyv

Report of Patient Services (RPS)

By law this form must be submitted for every monthly visit of patients with active tuberculosis.

All variables in *blue and asterisks* are mandatory fields.

If you have any questions about completing the Report of Patient Services, please contact the case manager who sent you the link to this form.

Patient Name:
	First	Middle	Last
Date of Birth:
Patient Address:
	Street	Apartment	City

	State	Zip
Chart Number (MRN):
Health Department Identifier (optional):
	If you are unsure if this number is correct or you do not have an MRN for this patient at your facility, please contact the health department representative who is working with you.
Patient Phone:
	Phone Number (10-digit US phone)	Phone Number (International)

*Did the patient have a visit scheduled this month?*

If patient had multiple visits scheduled this month, please provide information for the last kept visit this month.

*Date of Scheduled Visit*:

View equation

*Did the patient keep this visit?*

*Were medications prescribed?*

*Was this the patient's first visit?*

Date of Next Visit:

TB Site of Disease

(check all that apply)

Services Provided:		Management Course Status:
(Check all that apply)		(At time of last kept appointment)

According to services provided, no imaging was conducted for this scheduled visits.

Latest Imaging Type:
Body Site:
Latest Imaging Date:
Latest Imaging Result:

Was this most recent abnormal imaging cavitary?
Was this most recent abnormal imaging miliary?

Consistent with TB?

If prior imaging is available, is this image:

Was the patient prescribed anti-TB medications this visit?

How many medications was the patient prescribed? (Please only include medications for the treatment of tuberculosis.)

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Drug:			Months Prescribed:
Dose (mg):			Times per week:
Route of Intake:			Times per day:
Start Date:

Has the patient updated their pharmacy information since your last form submission?

Pharmacy Name:

Pharmacy Address:
	Street	City	Zip

Pharmacy Phone:

Is patient on Directly Observed Therapy?

*What date did the patient start DOT?*

Frequency of DOT per week:

Frequency of DOT per day:

Specify:

Would you like patient to be enrolled into DOT?

Provider Name:
	First	Last	Title
Provider Info:
	License Number	Hospital/Facility Name
Provider Phone:
	Phone Number	Ext.
Email Address:
	Email Address
Office Address:
	Street	City	Zip
Form prepared by: (full name)

Is there any additional information you would like to provide regarding this visit?

The NYC DOHMH offers low to no cost testing, treatment and care for TB. The BTBC case manager for your patient can provide more information about these services.

Date completed:

M-D-Y H:M

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Report of Patient Services (RPS)

By law this form must be submitted for every monthly visit of patients with active tuberculosis.

Patient Information

Visit Information

Imaging/X-ray

TB Medications

Pharmacy Information

Directly Observed Therapy

Healthcare Provider Information

Notes (optional)

You have selected an option that triggers this survey to end right now.