PDF
Word
MDH Form 5004 Physician's Confidential Report of Known or Suspected Pesticide-Related Illness - Maryland
What Is MDH Form 5004?
This is a legal form that was released by the Maryland Department of Health - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is MDH Form 5004?
A: MDH Form 5004 is a Physician's Confidential Report of Known or Suspected Pesticide-Related Illness specific to Maryland.
Q: What is the purpose of MDH Form 5004?
A: The purpose of MDH Form 5004 is to gather information about known or suspected pesticide-related illnesses in Maryland.
Q: Who should fill out MDH Form 5004?
A: MDH Form 5004 should be filled out by physicians or healthcare providers when they become aware of a known or suspected pesticide-related illness in a patient.
Q: Is MDH Form 5004 confidential?
A: Yes, MDH Form 5004 is a confidential report and its purpose is to collect data for epidemiological surveillance.
Q: What information is required on MDH Form 5004?
A: MDH Form 5004 requires information such as patient demographics, pesticide exposure details, symptoms, and laboratory test results.
Q: How should MDH Form 5004 be submitted?
A: MDH Form 5004 should be submitted by mail or fax to the Maryland Department of Health.
Form Details:
- Released on July 1, 2022;
- The latest edition provided by the Maryland Department of Health;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of MDH Form 5004 by clicking the link below or browse more documents and templates provided by the Maryland Department of Health.
