CureTB Referral Outcome Notification

CureTB Referral Outcome Notification
Division of Global Migration Health | E-mail: [email protected]
Telephone: 619-542-4013 Web address: www.cdc.gov/cureTB

Date:
To:

From:

Phone/Fax:

Phone:

Email:

Email:

Patient Name:
DOB:

A:

ID Number:

Referring Org.:

; BOP:

; USM:

; Other:

Date Referral Received:

Referral made by:
Phone:

E-Mail:

CureTB Referral Manager:
E-Mail:

Phone:
Referral outcome:

Preliminary

Final

Active/Verifed TB Patient:
Continues treatment

Died Date:

Cured Date:
(Used in for cases with negative smears at the
end of treatment.)

Completed treatment Date:
(Used in for cases without smear collection at the
end of treatment.)

Lost- Insufficient initial information to locate patient

Refused/Abandoned treatment

Lost- Arrived, but lost to follow-up

Treatment stopped by provider

Lost- Never found at intended location

Referral Not Required*

Moved back to US: City:
Clinical History Request:

, State:

Obtained*

Not Obtained

Referral Not Required*

*Comments:

This document is intended only for the use of the party to whom it is addressed and may contain information that is privileged, confidential, and protected from disclosure under
applicable law. If you are not the addressee, or a person authorized to deliver the document to the addressee, you are hereby notified that any review, disclosure, dissemination, copying
or other action based on the content of this communication is not authorized.

How are we doing?
Revised 10/2022

CS287149A