10 Provider Address The geographical location or Need provider's contact mailing address of the provider's information in to follow up office or facility. Address must appropriately for reportable event include street address, office or to ensure appropriate treatment, suite number (if applicable), city identify contact exposures, etc. or town, state, and zip code. 11 Facility ID Number Identification code for the facility Need provider's contact (e.g., Facility NPI) information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 12 Facility Name The facility's name Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 13 Facility Type The type of facility where patient Used to determine the type of received or is receiving healthcare care setting in which patient is for the reportable condition (e.g., receiving care for the reportable hospital, ambulatory, urgent care, condition. etc.) 14 Facility Phone The facility's phone number with Need provider's contact area code information in to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 15 Facility Address The mailing address for the facility Need provider's contact where patient received or is information in order to follow up receiving healthcare for the appropriately for reportable event reportable condition. Must to ensure appropriate treatment, include street address, city/town, identify contact exposures, etc. county, state, and zip code. 16 Patient ID Number Patient social security number, Identification and contact; medical record number, or jurisdictions may select which identifying value as required or they can receive based on laws allowed under jurisdictional laws governing public health data governing health data exchange. exchange 17 Patient Name All names for the patient, Identification and contact including legal names and aliases. Must include the name type (i.e., legal or alias), first name, middle name, and last name.
10 Provider Address The geographical location or mailing address of the provider's office or facility. Address must include street address, office or suite number (if applicable), city or town, state, and zip code. Need provider's contact information in to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 11 Facility ID Number Identification code for the facility (e.g., Facility NPI) Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 12 Facility Name The facility's name Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 13 Facility Type The type of facility where patient received or is receiving healthcare for the reportable condition (e.g., hospital, ambulatory, urgent care, etc.) Used to determine the type of care setting in which patient is receiving care for the reportable condition. 14 Facility Phone The facility's phone number with area code Need provider's contact information in to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 15 Facility Address The mailing address for the facility where patient received or is receiving healthcare for the reportable condition. Must include street address, city/town, county, state, and zip code. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. 16 Patient ID Number Patient social security number, medical record number, or identifying value as required or allowed under jurisdictional laws governing health data exchange. Identification and contact; jurisdictions may select which they can receive based on laws governing public health data exchange 17 Patient Name All names for the patient, including legal names and aliases. Must include the name type (i.e., legal or alias), first name, middle name, and last name. Identification and contact
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