Healthcare Provider Survey

Notify the Health Department within 24 hours of all reportable diseases. This reporting is expressly allowed under HIPAA and required by Michigan Public Act 366 of 1978, 333.511.

Please contact the Communicable Disease Nurses with any questions.
Jana Snider, 517-788-4655, jsnider@mijackson.org
Tracy Payne, 517-788-4655, tpayne@mijackson.org

Click here to view reportable diseases in Michigan by Condition.
Click here to view report diseases in Michigan by Pathogen.

1. Contact and Practice Information

Your Name

Practice Name

Street Address

Apt/Suite/Office

City

State

Zip

Phone Number

2. Patient's Information

Patient's Full Name

Parent/Guardian's Name (if patient is less than 18 years of age)

Patient's Address

Patient's Phone Number

Patient's Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Patient's Sex

Patient's Race

American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White/Caucasian
Unknown
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

4. Please upload a document/lab/encounter notes.

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We generally receive a better response from patients if they have been informed by their physician of their diagnosis before we contact them. We would appreciate it if you could call them and let them know the Health Department will be calling them in the next day or so. Thank you!

Healthcare Provider Survey

JCHD Healthcare Provider Reporting Form