Agency Name Reporting Month Date of Report 30-Day Clinical Alert HTN Last Name, First Name, Address, Health Behavior Option / Re- Value Mgt Zip Code & DOB Screen Date DOV Follow-Up including Quit Line screen Telephone Number Referral BP BG Yes Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Agency Name Reporting Month Date of Report Last Name, First Name, Address, Zip Code & Telephone Number DOB Re- screen Screen Date DOV Clinical Alert Value HTN Mgt Health Behavior Option / Follow-Up including Quit Line Referral 30-Day BP BG Yes Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
f01421.docx