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Alaska Confidential HIV/STD Report Form

Alaska providers report gonorrhea, chlamydia and syphilis cases to the Section of Epidemiology's HIV/STD Program on this 1-page fillable form. It captures the reason for exam, HIV status and PrEP use, diagnosis details, positive sites, syphilis stage and titers, treatment given or prescribed, and partner treatment. Cases must be reported within 2 working days under 7 AAC 27.005 and 27.007.

Who completes it

The diagnosing clinician or clinic staff complete the whole form, including the reporting clinic, the diagnosing clinician and the person completing it.

Submitting and payment

How to submit it
Fax the form to the HIV/STD Program's confidential fax line printed on it within 2 working days of diagnosis.
Who pays
There is no fee to file, and the form has no billing section.

Good to know

  • Treatment checkboxes follow CDC guidelines, such as ceftriaxone for gonorrhea, doxycycline for chlamydia and Bicillin L-A for syphilis, with dates administered or prescribed.
  • Partner management asks how many partners were treated after evaluation and how many received expedited partner therapy (EPT).
  • Syphilis staging runs from primary and secondary to early latent (under 1 year), unknown duration or late, and congenital, with neurologic, otic or ocular manifestations.
  • Gonorrhea and chlamydia sections record the diagnosis type, such as PID or disseminated infection, and every site that tested positive.

Get the official form

Download the current version from the source each time; forms change without notice.

Confidential HIV/STD Report Form

Official pagePDF

How this list is checked

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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Frequently asked questions

How soon must STDs be reported in Alaska?

The form states that cases must be reported within 2 working days, citing 7 AAC 27.005 and 7 AAC 27.007. Providers fax it to the Section of Epidemiology's confidential line. Other infectious diseases go on the separate Confidential Infectious Disease Report Form.

Does the Alaska HIV/STD form record expedited partner therapy?

Yes. The partner management section asks for the number of partners treated after an in-person evaluation and the number for whom the provider prescribed or provided an expedited partner therapy medication pack.