Nebraska Department of Health and Human Services
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Nebraska Parkinson's Disease Registry
Reporting Forms

We are currently developing an on-line submittal form to provide easy, efficient and secure reporting.   In the interim, please submit your information electronically or use the forms provided from this page.

Information should be sent on disc or paper via U.S. Mail. If you choose to submit your information by disc, please use the following data format:

   MS Word Physicians                 MS Word Pharmacies

Please DO NOT submit HIPAA protected information via email without it being encrypted or assigned a password to be sent in a separate email.

Pharmacies: The Reportable List of Drugs (in any generic or brand name form) effective January 1, 2008:

  • Azilect
  • Carbidopa/levodopa
  • Comtan
  • Mirapex
  • Neupro
  • Requip
  • Selegiline (except Emsam)
  • Stalevo
  • Tasmar

If you have no patients to submit for your semi-annual report, please send an email: jill.krause@dhhs.ne.gov.   Please state that you have no patients to report, why (for example, you are a specialty pharmacy), the time period included, and your pharmacy name and address.

When reporting by email, please enter your pharmacy name (and branch number, if applicable) in the subject line.

Pharmacy and physician forms should be sent to:
Jill Krause
NE Department of Health and Human Services
Public Health/Health Statistics
PO Box 95026
Lincoln, NE  68509-5026

  Forms

  • Physician Form

PDF PDF   MS Word Word

  • Pharmacists Form

PDF PDF    MS Word Word

  • Self-Report Form

PDF PDF    MS Word Word

 

Documents in PDF PDF format require the use of Adobe Acrobat Reader
which can be downloaded for free from Adobe Systems, Inc.

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