How to Complete and Submit the Florida Practitioner Disease Report Form

Florida’s Practitioner Disease Report Form, DH Form 2136, is the one-page document you use to notify the Department of Health when you diagnose or suspect a reportable disease. Complete the three blocks on the form (patient, medical, and provider information), attach any lab results, and send it to the county health department where the patient lives. For urgent diseases you also phone the county health department before any paperwork goes out. Missing a report is a second-degree misdemeanor carrying a fine of up to $500 per violation.¹

Who Has to File One

Florida Statute 381.0031 obligates any practitioner licensed in the state to practice medicine, osteopathic medicine, chiropractic medicine, naturopathy, or veterinary medicine to report diseases of public health significance. The statute also reaches licensed pharmacists authorized to order and evaluate lab tests, hospitals licensed under Part I of Chapter 395, and CLIA-certified laboratories.² Rule 64D-3.030 extends the duty to nurses, midwives, and medical examiners, and it makes clear that a lab’s report to the county health department does not relieve the practitioner of the separate obligation to file.³ If you treated the patient, you file.

Know Your Deadline Before You Start

How fast you have to move depends on which disease you are reporting. Rule 64D-3.029 sorts reportable conditions into three urgency tiers.⁴

Suspect immediately. Call the county health department without delay as soon as you suspect the condition, even before confirmation. Covered diseases include anthrax, botulism, cholera, diphtheria, measles, plague, smallpox, tularemia, viral hemorrhagic fevers, and yellow fever. The written DH Form 2136 follows within 72 hours.
Immediately. Call without delay once you have an indicative or confirmatory test result or diagnosis. This tier includes COVID-19, hepatitis A, listeriosis, pertussis, hemolytic uremic syndrome, and rabies in animals or humans. Written follow-up is also due within 72 hours.
Next business day. Report before the county health department closes on its next business day following suspicion or diagnosis. This tier covers chlamydia, gonorrhea, campylobacteriosis, cryptosporidiosis, dengue, giardiasis, and many others.

A request for a laboratory test to identify any listed agent counts as a suspicion of disease under the rule, but practitioners only need to report suspected cases for the “suspect immediately” conditions.³ The complete list of reportable diseases with their assigned timeframes is maintained on the Department of Health’s disease surveillance page.⁵

Filling Out the Form

DH Form 2136 is a single page in three blocks. Download the current version from the Department of Health, fill it in electronically before printing or faxing, and get county contact information from www.FloridaHealth.gov/CHDEpiContact.⁶

Patient Information

The top block collects identifiers: last name, first name, middle initial, Social Security number, and medical record number. Enter the patient’s home address, city, state, ZIP code, and county, plus home phone, an alternate phone, an emergency phone, and email. For a minor, add the parent’s name. Demographic fields cover date of birth, gender (male, female, unknown), race, ethnicity (Hispanic, non-Hispanic, unknown), and for female patients, pregnancy status.⁶

Medical Information

The middle block captures the clinical picture. Enter the date of symptom onset, the date of diagnosis, and the specific disease or condition. Indicate whether the patient died (with death date) and whether they were hospitalized (with facility name, admission date, and discharge date), and record the patient’s insurance information. Mark whether the patient was treated and specify the treatment, and note whether lab testing was performed. If results are available, attach them rather than transcribing into free-text fields.⁶

Provider Information

The bottom block identifies you: name, practice address, city, state, ZIP code, phone, fax, and email. The form has no field for your license number, but Rule 64D-3.030 does require your name, address, and telephone number so the county can verify and follow up.³

Lab and Diagnostic Data Required by Rule

Rule 64D-3.030 requires several additional data points that go beyond the printed fields. Include them on the form where they fit or on an attached document: the type of diagnostic test (culture, IgM, serology, skin test, nucleic acid amplification, etc.), specimen type (stool, urine, blood, mucus, and so on), date of collection, anatomical site if applicable, and the test results with reference ranges and titers for quantitative procedures. For tuberculosis, include the 15-digit spoligotype octal code.³ When you order a lab test for a reportable agent, you are also responsible for providing the patient’s identifying information to the lab at the time the specimen is sent. The county may follow up with additional epidemiological questions or request further specimen collection.

Where to Send the Completed Form

All reports go to the county health department where the patient lives, not where your office is. County fax numbers and contacts are at www.FloridaHealth.gov/CHDEpiContact.⁶

Phone First for Urgent Conditions

For anything in the “suspect immediately” or “immediately” tier, call the county health department first. Use the statewide emergency reporting number after hours. The completed DH Form 2136 follows within 72 hours by fax, electronic data transfer, or other confidential means.⁴ Even if your practice is fully set up for electronic reporting, the phone call still has to happen for these tiers.

Fax

Faxing to the correct county health department is the default for most practices. Keep the transmission confirmation as proof you met the deadline. The Bureau of Epidemiology also accepts faxed reports at 850-414-6894 as a backup.⁵

Electronic Submission

Two electronic pathways exist. Electronic Case Reporting (eCR) pushes case data from a certified EHR to public health agencies in real time through the APHL AIMS Platform; your EHR has to appear on the certified health IT products list, and onboarding runs through registration, vendor configuration, and testing. Electronic Laboratory Reporting (ELR) handles HL7 or CSV files over secure file transfer, with a web portal available for manual entry or batch submission when your systems cannot produce those file formats.⁵

Conditions That Use a Different Form

Three categories do not use DH Form 2136. Report HIV/AIDS cases and HIV-exposed newborns on the CDC’s Adult HIV/AIDS Confidential Case Report Form (CDC 50.42A) for patients 13 and older or the Pediatric form (CDC 50.42B) for younger patients. Cancer cases go to the Florida Cancer Data System. Congenital anomalies and neonatal abstinence syndrome are reported through inpatient discharge data submitted to the Agency for Health Care Administration under Chapter 59E-7 of the Florida Administrative Code.⁶

Confidentiality and Liability

Filing a report does not breach the practitioner-patient relationship. Florida Statute 381.0031 makes the information in disease reports confidential and exempt from public records disclosure under Section 119.07(1), releasable only when necessary to protect public health, and shields practitioners, hospitals, laboratories, and their employees from liability or criminal penalties for providing patient records to the Department as part of disease reporting.² Federal law aligns: 45 CFR 164.512 lets HIPAA-covered entities disclose protected health information without patient authorization when a disclosure is required by law or directed to a public health authority for disease surveillance.⁷

Penalties for Not Reporting

Failing to report a notifiable disease is a second-degree misdemeanor under Rule 64D-3.047. Each missed report is a separate offense, and conviction carries a fine of up to $500 per violation. Violations by practitioners, hospitals, or laboratories are also reported to the relevant professional licensing authority and public financing programs, which can open separate disciplinary proceedings.¹

1
Legal Information Institute. Florida Admin Code Ann R 64D-3.047 – Enforcement and Penalties
2
Online Sunshine. Florida Statutes 381.0031
3
Legal Information Institute. Florida Admin Code Ann R 64D-3.030 – Notification by Practitioners
4
Legal Information Institute. Florida Admin Code Ann R 64D-3.029 – Diseases or Conditions to Be Reported
5
Florida Department of Health. Disease Surveillance and Reporting
6
Florida Department of Health. Practitioner Disease Report Form
7
eCFR. 45 CFR 164.512 – Uses and Disclosures for Which an Authorization or Opportunity to Agree or Object Is Not Required