Minnesota health care providers use this confidential report form for lab-confirmed chlamydia and gonorrhea in Minnesota residents, as Minnesota Rule 4605.7040 requires. Beyond the diagnosis, it captures specimen sources, treatment date and regimen, and whether expedited partner therapy was given. Since September 2025 the same report can be submitted online through MDH's REDCap form.
The diagnosing provider completes the whole form, and a separate 'reported by' field covers staff who submit it for them. There is no patient section.
Download the current version from the source each time; forms change without notice.
Minnesota Confidential Chlamydia and Gonorrhea Report Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yes. Since September 2025, MDH has offered the report as an online REDCap form. Paper forms can still be faxed to MDH without a cover sheet, and mailing a copy is optional if you already faxed it.
Lymphogranuloma venereum is a reportable type of chlamydia in Minnesota, and MDH posts separate LGV testing and reporting guidance. Syphilis goes on the separate Minnesota Confidential Syphilis Report Form, and congenital syphilis and chancroid are reported to MDH by phone.
Name, medical record number, date of birth, address (or homeless or unknown), gender, race, ethnicity and phone, plus whether the patient had symptoms when tested, pregnancy with weeks and due date, HIV testing at the visit and whether the patient is on PrEP.