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Minnesota Confidential Syphilis Report Form

Minnesota providers report lab-confirmed syphilis in Minnesota residents to MDH on this two-page confidential form, as Minnesota Rule 4605.7040 requires. Page 1 covers the patient, partner details for MDH partner services and the provider; page 2 records the tests, the stage (primary, secondary, early latent, late latent or unknown duration, neurosyphilis or ocular syphilis) and treatment.

Who completes it

The diagnosing provider completes both pages, and a 'reported by' field allows staff to submit on their behalf. Partner information is optional and given when the provider wants MDH help with partner notification.

Submitting and payment

How to submit it
Fax the completed form to MDH's STD/HIV/TB Section, with no cover sheet needed, or mail it in an envelope marked confidential. MDH lists no online option for syphilis reports.
Who pays
MDH lists no fee or billing code for the report.

Good to know

  • Congenital syphilis and chancroid are reported to MDH by phone, not on this form.
  • Neurosyphilis must be accompanied by a staged diagnosis, and the form also records ocular syphilis symptoms, onset date and treatment.
  • Partner information is private, and MDH says nothing that could identify your patient is revealed to partners; follow-up usually needs specific locating information.
  • Report only lab-confirmed cases; laboratory reports do not substitute for the provider's case report.

Get the official form

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

Minnesota Confidential Syphilis Report Form

Official pagePDF

Fill it with Vero

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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 do I report congenital syphilis in Minnesota?

Call MDH's STD program. The syphilis report form's instructions say congenital syphilis and chancroid are reported by phone rather than on the form. HIV is reported separately, on MDH's HIV/AIDS confidential case report forms.

What does MDH need for partner follow-up?

Names and locating information for untreated partners, such as address, phone, email, screen name, age, date of last exposure and a physical description, plus the number of partners in the last 60 days. MDH says follow-up usually cannot start without specific locating information.

Does the form record pregnancy?

Yes. Page 1 asks whether the patient is pregnant, the number of weeks and the due date. On page 2, the reason for the test can be marked as pregnancy, signs or symptoms, screening, exposure or other, alongside the non-treponemal, treponemal and CSF-VDRL results.