Arizona requires health care providers to report selected communicable diseases under Arizona Administrative Code R9-6-202, and this 1-page fillable form is the paper option from ADHS. It collects patient information, the reportable condition with onset and diagnosis dates, lab results, and disease-specific details for chlamydia, gonorrhea, syphilis, congenital syphilis, HIV and tuberculosis, plus treatment and facility information.
The reporting provider or facility completes all three parts: patient information, reportable condition information and facility information, naming the provider if different from the reporter.
Download the current version from the source each time; forms change without notice.
Communicable Disease Report for Healthcare Providers
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The one Communicable Disease Report for Healthcare Providers includes sections for chlamydia, gonorrhea, chancroid, syphilis, congenital syphilis, HIV/AIDS and tuberculosis, alongside the general reportable condition and lab result fields.
Report through MEDSIS or fax the form to the local health agency for the patient's county. The form prints a fax number for each county, with separate STI and non-STI lines in Cochise and Maricopa counties.