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Practitioner disease report form 2025

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The document is a Practitioner Disease Report Form from the Florida Department of Health, designed for healthcare providers to report suspected or diagnosed cases of reportable diseases as per Florida Administrative Code 64D-3. It includes sections for patient information, disease specifics, provider details, and laboratory results, emphasizing the need for immediate reporting of certain diseases.

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Click ‘Get Form’ to open the practitioner disease report form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle initial, date of birth, and social security number without dashes. Provide their address, phone number (area code included), city, state, and zip code.
Indicate if the patient is pregnant and select their gender and race from the provided options. Specify ethnicity as either Hispanic or Non-Hispanic.
In the 'Disease Specific Information' section, indicate whether the disease is fatal and provide the date of onset. If applicable, include hospital details and discharge date.
Complete the 'Provider Information' section with your contact details and any relevant lab test information. Ensure to check if tests were conducted and provide results if available.
Finally, review all entries for accuracy before submitting your report through our platform.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (151 Votes)
2014	4.4 Satisfied (263 Votes)
2009	4 Satisfied (58 Votes)

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What is the process for reporting notifiable diseases?

How to report a suspected notifiable disease. If the case is an urgent notifiable disease, you must report it by telephone to your local UKHSA health protection team within 24 hours. This is to discuss actions to protect public health. Report all cases on the Report a notifiable disease online service within 3 days.

What disease is mandatory to report?

Mandatory written reporting: A report of the disease must be made in writing. Examples are gonorrhea and salmonellosis. Mandatory reporting by telephone: The provider must make a report by phone. Examples are rubeola (measles) and pertussis (whooping cough).

What is the process of notifiable disease reporting from the case patient to the CDC?

Case reporting steps A person feels ill and goes to the doctor. A doctor diagnoses and/or a laboratory confirms a reportable disease. The hospital, healthcare provider, or laboratory sends the information about this case to the public health department. Identify and control disease outbreaks.

What are the reportable specified diseases?

Reportable diseases include carpal tunnel syndrome, severe cramp of the hand or forearm, occupational dermatitis, hand-arm vibration syndrome, occupational asthma, tendonitis or tenosynovitis of the hand or forearm, any occupational cancer and any disease attributed to an occupational exposure to a biological agent.

How do I report a communicable disease in Florida?

Disease Reporting and Surveillance 850-245-4401. Florida Department of Health. 4052 Bald Cypress Way. Tallahassee, FL 32399.