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Fill Out Your Maryland Confidential Morbidity Report Template

The Maryland Confidential Morbidity Report (DHMH 1140) is a form designed for use by physicians and other healthcare providers to report specific diseases and conditions. This report is essential for tracking public health trends and ensuring timely interventions. To assist in the reporting process, healthcare providers can fill out the form by clicking the button below.

Launch Maryland Confidential Morbidity Report Editor

Fill Out Your Maryland Confidential Morbidity Report Template

Article Structure

Dos and Don'ts

Do's:

Provide complete and accurate patient information, including name, date of birth, and contact details.
Select the correct ethnicity and race options as applicable.
Indicate the disease or condition accurately, including the date of onset.
Notify the patient about their condition before submitting the report.
Include laboratory test results and attach copies of lab reports when possible.
Check all applicable boxes related to the patient's occupation or contact with vulnerable persons.
Ensure all dates are filled out correctly, including admission and death dates if applicable.
Provide your contact information as the reporter.
Submit the report to the correct local health department.

Don'ts:

Do not leave any required fields blank.
Avoid using abbreviations that may confuse the reader.
Do not submit the form without verifying all information for accuracy.
Do not report information that is not relevant to the case.
Refrain from including personal opinions or comments unrelated to the patient's condition.
Do not forget to check for updates on reporting requirements.
Do not submit the form to the wrong department or organization.
Avoid sharing sensitive patient information without consent.
Do not ignore follow-up requests from the health department for additional information.

Misconceptions

Misconception 1: Only doctors can submit the Maryland Confidential Morbidity Report.

This form is not limited to physicians. Other health care providers can also complete and submit it. It is essential for anyone involved in patient care to understand their role in reporting.

Misconception 2: The report is only for infectious diseases.

While the report does focus on certain conditions, it encompasses a variety of morbidity data. This includes chronic diseases and other health conditions that may impact public health.

Misconception 3: Submitting the report is optional.

Submitting the Maryland Confidential Morbidity Report is a legal requirement for certain conditions. Health care providers must comply to ensure the health department can monitor and manage public health effectively.

Misconception 4: Patient confidentiality is not protected.

Confidentiality is a cornerstone of this reporting system. The information collected is protected under state and federal laws, ensuring that patient identities remain confidential.

Misconception 5: The report is only for local health departments.

While the report is sent to local health departments, it contributes to a larger state database. This data helps in tracking trends and outbreaks across Maryland.

Misconception 6: The form is outdated and not relevant.

The Maryland Confidential Morbidity Report is regularly updated to reflect current public health needs. Providers should always use the latest version to ensure compliance and accuracy.

Misconception 7: There are no consequences for failing to report.

Failure to submit required reports can lead to legal repercussions for health care providers. It is crucial to prioritize reporting to avoid potential penalties and ensure community safety.

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Key takeaways

Understand the Purpose: The Maryland Confidential Morbidity Report form is designed for physicians and healthcare providers to report specific diseases and conditions. Laboratories have separate forms for reporting.
Complete Patient Information: Accurately fill in the patient’s name, date of birth, age, sex, and ethnicity. This information is crucial for proper identification and follow-up.
Specify Disease or Condition: Clearly indicate the disease or condition being reported. Include the date of onset and hospital admission if applicable.
Notify the Patient: Confirm whether the patient has been notified of their condition. This is an important step in maintaining transparency and trust.
Document Laboratory Tests: Include results from relevant laboratory tests. Attach copies of lab reports whenever possible to support your findings.
Provide Clinical Information: Offer pertinent clinical information and any additional comments that may assist the local health department in understanding the case better.
Follow Up: Your local health department may reach out after the initial report for further information. Be prepared to provide additional details if requested.

Guidelines on Utilizing Maryland Confidential Morbidity Report

Once the Maryland Confidential Morbidity Report form is completed, it must be submitted to your local health department. Ensure all information is accurate and thorough, as this report plays a crucial role in public health monitoring and response. After submission, your local health department may reach out for any additional details needed regarding the case.

Obtain the Maryland Confidential Morbidity Report form (DHMH 1140).
Fill in the STATE DATA BASE NUMBER, which will be completed by the health department after submission.
Enter the NAME OF PATIENT with the last name first, followed by the first name and middle initial.
Provide the DATE OF BIRTH in month, day, and year format.
Indicate the AGE and SEX of the patient.
Specify the ETHNICITY by selecting one of the options provided.
List the TELEPHONE NUMBERS for the patient, including home and workplace numbers.
Fill in the ADDRESS, including unit number, city or town, state, and ZIP code.
Identify the COUNTY where the patient resides.
Document the OCCUPATION OR CONTACT WITH VULNERABLE PERSONS and provide details of the workplace, school, or child care facility.
Indicate if the patient is a HEALTH CARE WORKER, DAYCARE ATTENDEE OR WORKER, or other specified roles.
Describe the DISEASE OR CONDITION and provide the DATE OF ONSET.
Note the DATE ADMITTED to the hospital, if applicable.
State whether the PATIENT HAS BEEN NOTIFIED OF THIS CONDITION.
Confirm if the CONDITION WAS ACQUIRED IN MARYLAND and identify the SUSPECTED SOURCE OF INFECTION.
Indicate if the patient DIED and provide the DATE DIED if applicable.
Specify if the patient is PREGNANT and provide additional details, including weeks pregnant and due date.
Fill in the LABORATORY TESTS results as required, including details for viral hepatitis tests.
Provide any PERTINENT CLINICAL INFORMATION and additional comments.
Complete the section for HIV/AIDS if applicable, including lab test results.
Check the boxes for any assistance requested from the local health department.
Fill out the REPORTED BY section, including your address and telephone number.
Enter the DATE OF REPORT in month, day, and year format.
Review the entire form for accuracy before submitting it to your local health department.

Form Preview Example

MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)

(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)

SEND TO YOUR LOCAL HEALTH DEPARTMENT

STATE DATA BASE NUMBER (Completed by Health Department)

NAME OF PATIENT

– LAST

FIRST

DATE OF BIRTH

AGE

SEX

ETHNICITY (Select independently of RACE)

MONTH

DAY

YEAR



HISPANIC or LATINO:

YES 

NO 

UNKNOWN 



TELEPHONE NUMBERS

RACE (Select one or more. If multiracial, select all that apply)

Home:

Workplace:

American Indian/Alaskan Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

Unknown 

Other (Specify):

ADDRESS

UNIT#

CITY OR TOWN

STATE

ZIP CODE

COUNTY

OCCUPATION OR CONTACT WITH VULNERABLE PERSONS

WORKPLACE, SCHOOL, CHILD CARE FACILITY, ETC.

( Include Name, Address, ZIP Code)

(Check all that apply - include volunteers)

 HEALTH CARE WORKER (Include any PATIENT CARE, ELDER CARE, "AIDES," etc.)

 DAYCARE (Attendee or Worker)

 PARENT of a child in DAYCARE

 FOOD SERVICE WORKER

 NOT EMPLOYED

 OTHER (SPECIFY):

DISEASE OR CONDITION

DATE OF ONSET

ADMITTED

DATE ADMITTED

HOSPITAL

MONTH

DAY

YEAR

YES



MONTH

DAY

YEAR

PATIENT HAS BEEN NOTIFIED OF THIS CONDITION

YES 

NO 



CONDITION ACQUIRED IN MARYLAND

SUSPECTED SOURCE OF INFECTION

DIED

DATE DIED

PREGNANT

YES 

NO 

UNKNOWN 

YES



MONTH

DAY

YEAR

YES 

NO 

UNKNOWN 

NOT APPLICABLE 

(IF NO, INTERSTATE , or INTERNATIONAL  )



WEEKS PREGNANT __________

DUE DATE ____________________

LABORATORY TESTS - VIRAL HEPATITIS

ADDITIONAL LAB RESULTS

POS

NEG

DATE

POS

NEG

DATE

HCV Viral Genotyping

____________

DATE _____________

(SPECIMEN - TEST - RESULT - DATE - NAME of LAB)

(Please attach copies of lab reports whenever possible.)

HAV Antibody Total



_____________________

HBV surface Antibody



_____________________

ALT (SGPT) Level

______________

DATE

______________

HAV Antibody IgM



_____________________

HBV Viral DNA



_____________________

ALT – Lab Normal Range:

______________ to _____________

HBV surface Antigen



_____________________

HCV Antibody ELISA



_____________________

AST (SGOT) Level

____________

DATE _____________

HBV e Antigen



_____________________

HCV ELISA Signal/Cut Off Ratio

_____________________

AST – Lab Normal Range: ______________ to

____________

HBV core Antibody Total



_____________________

HCV Antibody RIBA



_____________________

NAME of LAB:

________________________________________

HBV core Antibody IgM



_____________________

HCV RNA (eg., by PCR)



_____________________

PERTINENT CLINICAL INFORMATION + OTHER COMMENTS

HUMAN IMMUNODEFICIENCY VIRUS (HIV) and			–	ADDITIONAL CASE INFORMATION
ACQUIRED IMMUNODEFICIENCY SYNDROME		(AIDS)	–	ADDITIONAL CASE INFORMATION
CON D IT IO NS		H IV L AB T EST S			D AT E	RESULT
WEIGHT LOSS OR DIARRHEA .............................................	CD4+	T-cells < 200 per microliter or < 14%
SECONDARY INFECTIONS (PCP, TB, etc.).........................
	ELISA
PERINATAL EXPOSURE OF NEWBORN .............................
	WESTERN BLOT
OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION  (SPECIFY):
OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION  (SPECIFY):	OTHER (SPECIFY):

PHYSICIAN REQUESTS LOCAL HEALTH DEPARTMENT TO ASSIST WITH: NOTIFICATION TO PATIENT YES  NO  PARTNER SERVICES YES  NO 

SEXUALLY TRANSMITTED INFECTION (STI) –						ADDITIONAL CASE INFORMATION
SYPHILIS: PRIMARY 	SECONDARY 	EARLY LATENT (LESS THAN 1 YR) 			CONGENITAL 	OTHER STAGE  (SPECIFY):

GONORRHEA: CERVICAL 	URETHRAL 	RECTAL 	PHARYNGEAL 	OPHTHALMIA NEONATORUM 		PID  OTHER  (SPECIFY):

CHLAMYDIA: CERVICAL 	URETHRAL 	RECTAL 	PHARYNGEAL 	PID 	OTHER  (SPECIFY):

OTHER STI (Specify):

STI LABORATORY CONFIRMATION AND TREATMENT

Specify STI Lab Test (e.g., RPR Titer, FTA – TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL - CSF)

DATE

TEST

RESULT

STI Treatment Given  (Specify date – drug – dosage below)		No Treatment Given 
DATE	DRUG	DOSAGE

TUBERCULOSIS (Suspect or Confirmed) – ADDITIONAL CASE INFORMATION

MAJOR SITE: PULMONARY 

EXTRAPULMONARY 

ATYPICAL  (SPECIFY )

ABNORMAL CHEST X-RAY: 

COMMENTS:

REPORTED BY

ADDRESS

TELEPHONE NUMBER

DATE OF REPORT

MONTH DAY YEAR

Check here if completed by the Health Department

NOTES: Your local health department may contact you following this initial report to request additional disease-specific information. To print blank report forms or get more information about reporting, go to http://ideha.dhmh.maryland.gov/SitePages/what-to-report.aspx.

DHMH 1140 REVISED JANUARY 26, 2012

Common mistakes

Incomplete Patient Information: Failing to provide all necessary details about the patient, such as their full name, date of birth, and contact information, can lead to delays in processing the report.
Incorrect Ethnicity and Race Selection: Selecting ethnicity and race incorrectly or not understanding the distinction between the two can result in inaccurate demographic data.
Missing Disease or Condition Details: Omitting the specific disease or condition and its date of onset can hinder public health responses and tracking efforts.
Inaccurate Laboratory Test Results: Reporting lab results incorrectly or neglecting to include necessary laboratory tests can compromise the quality of the data collected.
Failure to Notify Patient: Not indicating whether the patient has been notified of their condition can lead to miscommunication and potential legal issues.
Omitting Follow-Up Information: Leaving out critical follow-up details, such as treatment given or additional comments, can prevent appropriate health interventions.

Free Maryland Confidential Morbidity Report PDF

Learn More on This Form

What is the purpose of the Maryland Confidential Morbidity Report form?

The Maryland Confidential Morbidity Report form is designed for healthcare providers to report specific diseases and conditions to local health departments. This report helps public health officials track and manage disease outbreaks, ensuring that appropriate measures are taken to protect community health. It is important for physicians and other healthcare providers to fill out this form accurately to facilitate timely responses to public health concerns.

Who is required to complete this form?

This form is primarily for use by physicians and healthcare providers. It's important to note that laboratories should not use this form; instead, they should utilize forms DHMH 1281 and DHMH 4492 for reporting. Healthcare providers, including those working in hospitals, clinics, and other medical settings, are responsible for submitting the report when they diagnose a reportable condition.

What information is needed to complete the form?

To complete the Maryland Confidential Morbidity Report form, healthcare providers must provide various details about the patient, including their name, date of birth, sex, ethnicity, and race. Additionally, information regarding the disease or condition, date of onset, hospital admission details, and laboratory test results must be included. It’s also essential to indicate if the patient has been notified of their condition and whether the condition was acquired in Maryland.

How is patient confidentiality maintained when using this form?

Patient confidentiality is a top priority when using the Maryland Confidential Morbidity Report form. The form is designed to be confidential, and the information collected is used solely for public health purposes. Local health departments are responsible for safeguarding this information and ensuring that it is only accessible to authorized personnel. Providers should take care to submit the form securely and avoid sharing any identifiable patient information outside of the reporting process.

What should I do if I need more information about reporting?

If you require additional information about how to report or need blank report forms, you can visit the Maryland Department of Health's website at http://ideha.dhmh.maryland.gov/SitePages/what-to-report.aspx. This site provides resources and guidance on the reporting process, ensuring that healthcare providers have the necessary tools to comply with reporting requirements effectively.