mdhhs-5908, PROVIDER SEXUALLY TRANSMITTED infection (STI)
TREATMENT REPORT

Michigan Department of Health and Human Services

Bureau of HIV and STI Programs

(Revised 2-23)

section 1- general information

Fax completed form to	Secure Fax Number 313-456-1580

Reporting Agency	Phone Number

Address	City	State	Zip Code

section 2 – information source

Information Source (check one) HIV Counseling and Testing Site STD Clinic Family Planning/Planned Parenthood Private Physician/Health Maintenance Organization (HMO)	Emergency Room (ER)/Urgent Care Labor and Delivery Prenatal Type Not Listed

section 3- patient information

Patient Name	Preferred Name

Date of Birth (MM-DD-YYYY)	Phone Number

Address	City	State	Zip Code

Sex at Birth Male Female	Pregnant on the date of testing? Yes No Unknown

Gender Male Female Transgender Male Transgender Female Nonbinary Other

Race Black White Asian Pacific Islander Native American/Alaskan Native Unknown Other

Ethnicity Hispanic Non-Hispanic Arab Unknown

HIV Status on date of testing Positive Negative Refused to Answer Not Tested

Gender of sex partners in past 12 months Male Female Transgender Male Transgender Female Nonbinary Other

Does patient have partners who require testing and treatment?

Number of partners already treated by provider

Number of partners already treated through expedited partner therapy (EPT)

section 4 – specimen and treatment information

Specimen Collection Date

Specimen Source Cervix Vagina Urine Urethra Rectum Pharynx Blood/Serum Other

Specimen submitted by (physician or institution)	Contact Phone Number

Laboratory that processed specimen	Date of lab results

Patient Treated? No Unknown Yes If yes, date of treatment

Disease Reported	Lab Confirmed	Presumptive Diagnosis
Gonorrhea
Chlamydia
Syphilis
Rapid Syphilis

Specify Treatment – Drug, Dosage, and Route (check all that apply) Azithromycin (Zithromax) 2g as single dose Azithromycin (Zithromax, Z-pak) 1 gram Ceftriaxone (Rocephin) 500mg IM 2.4 mU Bicillin IM x1 dose 2.4 mU Bicillin IM x3 doses 2.4 mU Bicillin IM x other or unspecified dose Doxycycline (Vibramycin) 100mg x2 per day, 7 days Doxycycline (Vibramycin) BID x 14 days Doxycycline (Vibramycin) BID x 28 days Levofloxacin (Levaquin) 500 mg Other Treatment (Specify drug, dose, and route)

Refer to CDC Guidelines at cdc.gov/std/treatment for current treatment recommendations.

Notes

Document Completed By	Date

The Privacy Rule in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows for the disclosure of protected health information, without individual client or patient authorization, to public health authorities, who are legally authorized to receive such reports for the purpose of preventing or controlling disease.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.