Healthcare Provider Amyotrophic Lateral Sclerosis (ALS) Reporting Form

Healthcare Provider Amyotrophic Lateral Sclerosis (ALS) Reporting Form

Act 149 (2022) requires healthcare providers that screens for, diagnoses, or provides therapeutic services to patients with ALS shall report to the Department all individuals diagnosed as having ALS not later than six months from the date of diagnosis, unless the provider knows that a report for that patient has already been made to the Department.

Name of Reporting Provider *This question is required.

Date of Report (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Reporting Provider Mailing Address *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

Phone Number *This question is required.

Please provide an email address to send a confirmation to, if desired.

Please indicate the following: “In the last calendar year, ...
(If you choose one of the options below, you do not need to fill out the rest of this form.)

none of my patients have been diagnosed with ALS."
all my patients with an ALS diagnosis have already been reported to the Department."