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Mississippi Form 135E Case Report Card (MSDH)

Mississippi providers use MSDH Form 135E, the Case Report Card for reportable diseases and conditions, to send a case to the Office of Epidemiology. Beyond patient and reporter details, the one-page fillable card (revised 8-17-12) has condition-specific blocks for hepatitis serology and liver chemistry, mycobacterial test results, and treatment for gonorrhea, chlamydia and syphilis.

Who completes it

The person reporting fills in the whole card, naming the attending physician and the hospital or clinic. There is no patient section.

Submitting and payment

How to submit it
Fax or mail the card to MSDH Epidemiology, never by email. Providers with an MSDH disease reporting account can instead submit online through EpiTracks, and MSDH lists phone lines for STD/HIV, TB and all other diseases, plus an after-hours number.
Who pays
MSDH lists no fee or billing code for the report.

Good to know

  • Individual case reports of influenza-like illness are not required, according to the card.
  • For gonorrhea, chlamydia or syphilis, including congenital syphilis, record the date treated, medication, dosage, frequency, duration and route (PO, IM or IV).
  • Mycobacterial fields include chest x-ray and CT findings, PPD and IGRA results, and smear and culture dates for sputum, tissue and body fluid specimens.
  • Poisonings, including potential exposures, overdoses, adverse reactions and venomous bites or stings, are reported to the Mississippi Poison Control Center instead.

Get the official form

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

Reportable Diseases and Conditions Case Report Card

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

Can I email the Mississippi case report card?

No. Form 135E is printed with 'Please do NOT email the Case Report Card.' Fax or mail it to MSDH Epidemiology, or use EpiTracks, MSDH's online disease reporting system, after requesting a disease reporting account. MSDH posts an EpiTracks user guide on its reporting page.

Where are Mississippi's reporting rules?

MSDH links the Mississippi Reportable Diseases List, revised October 2023, and the Rules and Regulations Governing Reportable Diseases on the Secretary of State's site from its reporting page. Those documents set out what must be reported; the card itself carries the case details.

What hepatitis details does Form 135E ask for?

Hepatitis A IgM, hepatitis B IgM and hepatitis C antibody results, whether the patient was jaundiced, pregnancy with EDC or delivery date, and total bilirubin, AST and ALT with the normal range for each test and the date of the chemistry test.