This field is filled in automatically.
Case Registration Date
Enter the date the paper form was completed.
This field is filled in automatically. If the patient already exists in the patient dictionary, click thebutton on the search bar:
The following box appears:
Select the radio button next to the desired search field (Patient ID, SSN, or other ID), enter the criterion, and click the Find button. If the patient record is found, all fields in Section 1 of the Case Registration form will automatically be filled in from the patient dictionary. If the patient does not already exist in the patient dictionary, enter the patient information described, below, to create a new patient record.
*SSN or Other ID
Either the patient’s social security number (SSN) or some other identification code must be provided, but not both.
To use the patient’s SSN, select the SSN radio button and enter the ID in the format NNN-NN-NNNN where N is a digit; all digits are required.
Use Other Identification
If you do not provide the social security number, click the button next to Use Other Identification. Enter the identification code in the Use Other Identification field, and a description of the code, such as Social Insurance Number, in the Description field. Entries in these fields cannot exceed 50 characters. Do not enter the Use Other Identification or Description fields if the social security number is provided.
First and last names must be 45 characters or less. At least two characters must be from the characters "A"-"Z", "a"-"z", or a single quote ('). Additional characters may include a hyphen.
Middle Name is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "."
Old Medicare Beneficiary ID (MBID)
Indicate the the patient's Medicare Beneficiary ID issued prior to April 2018. The format is primarily numeric, with 1-2 letters proceeding or following them.
New Medicare Beneficiary ID (MBID)
Indicate the the patient's Medicare Beneficiary ID issued after April 2018. This will usually be a combination of letters and numbers, 11 characters long.
*Date of Birth
Date of Birth must be at least three weeks prior to the current date.
Select the appropriate response.
Enter the patient’s race as identified by the patient. If the patient identifies with more than one race, select Other. This field is optional.
Patient Ethnicity (Hispanic Origin)
Enter whether the patient is of Hispanic origin, as identified by the patient. This field is optional.
Select the version of health insurance of the patient, if available.
Select the patient's level of education, if available.
COVID vaccination/vaccination date
Indicate if the patient has received the COVID vaccine and the date of vaccination, if available.
COVID vaccine manufacturer
Select the appropriate response.
COVID vaccine site
Enter the location where the patient received the COVID vaccine, if available.
Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date.
Name of Person Who Completed the Paper Form
Enter the name of the person who collected the data for this exam. If this name has not been previously entered in a case record, select Add New and enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.
Note: Please populate this field even if paper forms were not used; you may use the name of the person completing the on-line data submission.
To delete a name from the list, select it and then click the Delete Person button.
Name of person submitting form
These fields are filled in automatically.