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Get ID Public Health Reportable Disease Fax Report Form 2006-2024

Ty administrators are required to report infectious diseases, conditions or syndromes listed on Idaho’s reportable disease list (see back for list). Reportable disease reporting to the Panhandle Health DistrictPhone: (a public health authority) is in compliance with HIPAA. CONFIDENTIAL CASE REPORT FORM PATIENT INFORMATION Disease, Condition or Organism: Clinical Diagnosis Lab Confirmed Onset Date: Test Date: Patient’s Name (Last, First): Report Date: Is Patient Pregnant? Yes No Date .

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