Get Single Disease Report Form - Florida Department Of Health In ...

Filling out the Single Disease Report Form is an essential step for reporting diseases of public health significance in Florida. This guide provides comprehensive, step-by-step instructions for completing the form online, ensuring you can navigate the process efficiently and accurately.

Follow the steps to fill out the form online:

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. You will need to fill in the last name, middle initial, date of birth in MM/DD/YYYY format, social security number without dashes, and full address details including city, state, and zip code.
3. Indicate the patient’s gender by selecting the appropriate option.
4. Provide specific disease information. Record the date of onset and note whether the patient has been hospitalized by marking yes or no.
5. Fill in the ethnicity and race of the patient. Select the appropriate options provided.
6. For pregnancy status, indicate whether the patient is pregnant or not.
7. Include the hospital name and, if available, the Medicaid number or insurance details.
8. For specific diseases such as HIV/AIDS, ensure to report relevant details by phone as instructed on the form.
9. Provide the provider information, including the name, address, fax number, email, and phone number.
10. If any tests were conducted, include the lab results and the date of the lab test as well as any treatment provided.
11. Finally, review all entered information for accuracy, and proceed to save changes, download, print, or share the completed form as necessary.

Complete the Single Disease Report Form online to help keep Florida's communities safe.