Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska
Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska
Department of Health and Social Services DIVISION OF PUBLIC HEALTH Section of Epidemiology REFERRAL AND AUTHORIZATION FOR TB SCREENING AND FOLLOW-UP SERVICES DATE: ___________________________ PROVIDER/FACILITY:____________________________________________ CLIENT: _____________________________________________ DOB: ________________ SERVICE(S) REQUESTED: CHEST X-RAY (CPT 71010 Authorization #: _______________________ Single View reimbursement up to $125 allowed HEPATIC PANEL (CPT 80076) Authorization #: _______________________ reimbursement up to $110 allowed VENIPUNCTURE (CPT 36415) Authorization #: _______________________ reimbursement up to $40 allowed Other______________________ Authorization #: _______________________ NOTE: Reimbursement is ONLY available for the services authorized above. DIAGNOSIS: _________________________________________________________________ PHYSICIAN: Dr. Michael P. Cooper, State of Alaska Section of Epidemiology SERVICE(S) REQUESTED BY: __________________________________, PHN FAX REPORT/RESULTS TO: _________________________________ MAIL X-RAY CD/FILM TO: __________________________________________________ ______________________________________________________________________________ Please send invoice and this authorization to: Attn: Jessica Grantier Alaska DHSS, DPH, Section of Epidemiology/TB Program 3601 C Street, Ste. 540 Anchorage, AK 99503 Phone: (907) 269-8000 Fax: (907) 563-7868 Thank You for Your Time and Assistance 3601 C Street, Suite 540 Anchorage, Alaska 99503 Main: 907.269.8000 Fax: 907.562.7802 Rev 11/12
Instructions for Collecting Sputum Samples Why is a Sputum Test Necessary? Your doctor needs you to collect a sputum sample to test for tuberculosis (TB) in your lungs. Checking your sputum is the best way to find out if you have TB disease or to see if your treatment is working. To collect an acceptable sample you need to cough up sputum from deep inside of your lungs as soon as you wake up in the morning. The lab needs at least 5 mL of sputum. How to Collect a Sputum Sample 1. The TB sputum tube must not be opened until you are ready to use it. DO NOT REMOVE preservative (white powder) from the tube. 2. As soon as you wake up in the morning, before you eat or drink, rinse your mouth with WATER. 3. Take a very deep breath and hold air for 5 seconds. Slowly breathe out. Take another deep breath and cough hard until some sputum comes up into your mouth. 4. Spit the sputum into the TB tube. 5. Keep collecting until the sputum reaches the 5 mL line on the TB tube. 6. Screw the orange cap on the tube tightly so it doesn’t leak. 7. Wash and dry the outside of the TB tube. 8. Write your NAME, BIRTH DATE, and the DATE/TIME you collected the sputum on the tube and lab form. 9. Put the tube into the bag provided. 10. Deliver sample (s) to your Community Health Aide, doctor(s) office, or PHN AS SOON AS POSSIBLE. (Samples must be received at the Anchorage laboratory for testing within 10 days of collection.) 11. If you need to collect three TB samples, collect them in the morning on three different days, unless you are told otherwise. Keep in refrigerator until all are collected. Do not collect more than one per day. Alaska State Public Health Laboratory: 5455 Dr. Martin Luther King Jr. Ave., Anchorage, AK 99507 Phone: (907) 334-2100 Fax: (907) 334-2161 Alaska Tuberculosis Control Program: For more information about TB call Epidemiology at (907) 269-8000 or visit their website at: www.epi.hss.state.ak.us/id/tb.stm. Rev 8/11
- Page 373 and 374: Figure 1: TWO STEP TESTING AND FOLL
- Page 375 and 376: Isolation To reduce disease transmi
- Page 377 and 378: Table 4: CRITERIA FOR PATIENTS TO B
- Page 379 and 380: When to Initiate Airborne Infection
- Page 381 and 382: Confirmed Tuberculosis Disease A pa
- Page 383 and 384: Multidrug-Resistant Tuberculosis Di
- Page 385 and 386: Environmental Controls in the Patie
- Page 387 and 388: Return to Work, School, or Other So
- Page 389 and 390: Tuberculosis Infection Control in P
- Page 391 and 392: Transportation Vehicles To prevent
- Page 393 and 394: 7 CDC. Guidelines for preventing th
- Page 395 and 396: Forms: Alaska State Public Health L
- Page 397 and 398: ALASKA STATE PUBLIC HEALTH LABORATO
- Page 399 and 400: Anchorage Alaska State Public Healt
- Page 401 and 402: INDEX CASE INFORMATION Name: DOB: /
- Page 403 and 404: CONTACT Name: Tuberculosis Contact
- Page 405 and 406: Directly Observed Therapy (DOT) Cal
- Page 407 and 408: B. Documents patient care activitie
- Page 409 and 410: Alaska TB Program Section of Epidem
- Page 411 and 412: Treatment Summary for Active TB Nam
- Page 413 and 414: Interjurisdictional Tuberculosis No
- Page 415 and 416: ! !"#$%&'%()*(+#(,"-./0'1$%+'.,)()/
- Page 417 and 418: ! B!9:(78;7)3702D!! ! 3"#$%&%''98#5
- Page 419 and 420: ! ?"#51)09/02!H0/.!9:(78;7)37028!/'
- Page 421 and 422: Latent Tuberculosis Infection (LTBI
- Page 423: Alaska Tuberculosis Program 9210 Va
- Page 427 and 428: TB Case Management Information Requ
- Page 429 and 430: Table 1: First-line anti-tuberculos
- Page 431 and 432: Return the fax to the Drug Room (90
- Page 433 and 434: Stock Orders: A small supply of
- Page 435 and 436: TB/LTBI Medication Return Form Reas
- Page 437 and 438: TB/LTBI Stock Medication Request FA
- Page 439 and 440: TB Medication Dose Monitoring Regim
- Page 441 and 442: TB Medication Dose Monitoring Regim
- Page 443 and 444: ALASKA DEPARTMENT OF HEALTH AND SOC
- Page 445: Tuberculosis Discharge Planning Che
- Page 448 and 449: PART 2: 8. Have you ever been told
- Page 450 and 451: Tuberculosis Treatment Contract Dep
- Page 452 and 453: Statutes and Regulations Contents I
- Page 454 and 455: Regulations Infection Control 7 AAC
- Page 456 and 457: place of work is remote from patien
- Page 458 and 459: (2) the child or a person acting on
- Page 460 and 461: Glossary acid-fast bacilli (AFB): M
- Page 462 and 463: eaction size on a later test, which
- Page 464 and 465: disseminated TB: See miliary TB. dr
- Page 466 and 467: immunocompromised and immunosuppres
- Page 468 and 469: include medical history and TB symp
- Page 470 and 471: thousands to millions of copies of
- Page 472 and 473: secondary (TB) case: A new case of
Department <strong>of</strong><br />
Health and Social Services<br />
DIVISION OF PUBLIC HEALTH<br />
Section <strong>of</strong> <strong>Epidemiology</strong><br />
REFERRAL AND AUTHORIZATION FOR TB SCREENING AND FOLLOW-UP SERVICES<br />
DATE: ___________________________<br />
PROVIDER/FACILITY:____________________________________________<br />
CLIENT: _____________________________________________ DOB: ________________<br />
SERVICE(S) REQUESTED:<br />
CHEST X-RAY (CPT 71010 Authorization #: _______________________<br />
Single View reimbursement up to $125 allowed<br />
HEPATIC PANEL (CPT 80076) Authorization #: _______________________<br />
reimbursement up to $110 allowed<br />
VENIPUNCTURE (CPT 36415) Authorization #: _______________________<br />
reimbursement up to $40 allowed<br />
Other______________________ Authorization #: _______________________<br />
NOTE: Reimbursement is ONLY available for the services authorized above.<br />
DIAGNOSIS: _________________________________________________________________<br />
PHYSICIAN: Dr. Michael P. Cooper, <strong>State</strong> <strong>of</strong> <strong>Alaska</strong> Section <strong>of</strong> <strong>Epidemiology</strong><br />
SERVICE(S) REQUESTED BY: __________________________________, PHN<br />
FAX REPORT/RESULTS TO: _________________________________<br />
MAIL X-RAY CD/FILM TO: __________________________________________________<br />
______________________________________________________________________________<br />
Please send invoice and this authorization to:<br />
Attn: Jessica Grantier<br />
<strong>Alaska</strong> DHSS, DPH, Section <strong>of</strong> <strong>Epidemiology</strong>/TB <strong>Program</strong><br />
3601 C Street, Ste. 540<br />
Anchorage, AK 99503<br />
Phone: (907) 269-8000<br />
Fax: (907) 563-7868 Thank You for Your Time and Assistance<br />
3601 C Street, Suite 540<br />
Anchorage, <strong>Alaska</strong> 99503<br />
Main: 907.269.8000<br />
Fax: 907.562.7802<br />
Rev 11/12
Change language