Get Ca Apla Physician's Diagnosis Form 2013-2025

Filling out the CA APLA Physician's Diagnosis Form accurately is essential for documenting a patient's health status related to HIV and obtaining necessary services. This guide provides step-by-step instructions to assist you in completing the form online, ensuring all required information is properly recorded.

Follow the steps to fill out the CA APLA Physician's Diagnosis Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's name in the designated fields, including the last name, first name, and middle initial if applicable.
3. Provide the patient's Social Security number in the required format, following the specified example.
4. Select the appropriate diagnosis by checking the box for either 'HIV+ Asymptomatic,' 'HIV+ Symptomatic,' 'AIDS Asymptomatic,' or 'AIDS Symptomatic.'
5. Input the date of the diagnosis, specifically the year of the first positive test for HIV.
6. List any symptoms that substantiate the diagnosis by checking the relevant boxes, and fill in any other symptoms in the provided space.
7. Document any opportunistic infections that substantiate the diagnosis, including specific dates as necessary.
8. Detail the current symptoms related to HIV disease or treatment in the specified section.
9. For lab data, enter the CD4 count/percentage and HIV viral load along with the corresponding dates.
10. Fill in the neutrophil count, and platelet count along with the required dates.
11. Indicate if there are any other illnesses that need to be noted.
12. Specify if the patient is medically able to receive routine dental care or oral procedures.
13. Answer whether the patient needs food and nutrition services.
14. Record the results of any TB screening, including dates of tests and treatments.
15. Finally, the responsible physician must certify the information by entering their name, license number, address, signing, and providing the date of completion.
16. Once you have filled out all sections, save your changes in the editor, and download, print, or share the form as needed.

Complete your documents online to ensure timely processing and access to necessary services.