STD/DIS/MIDIS Question Submission Form
Welcome!
This form is designed to facilitate efficient communication between local public health and the MT DPHHS STD/DIS team regarding STDs and disease investigation. By submitting your questions through this form, you'll help streamline the process and ensure that your inquiries are directed to the appropriate team members for prompt and accurate responses. For each request, please fill out separate forms. Thank you!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is the best way to contact you?
Email
Phone
What is the best time of day to contact you?
If you are unavailable, is there a back-up individual to contact?
Yes
No
What is the name and contact information (phone and email) of the back-up individual?
Which of the following does your question/need pertain to?
Transferring a case to another jurisdiction or deleting a case
Case merging
MIDIS
Out of state record search
Previous history of syphilis or STD
Chlamydia or gonorrhea case investigation / partners
Clinical
Syphilis
Congenital syphilis
Other
Please select which you need assistance with
Transferring a case to another jurisdiction
Deleting a case
Please provide the case's MIDIS ID number:
Please provide the reason this case needs to be transferred/deleted.
Please provide the MIDIS ID number to merge:
Which MIDIS ID number would you like to survive in MIDIS?
Please provide the reason these cases need to be merged.
If your question is related to a specific case, please provide the case's MIDIS ID number:
Which STI(s) has the case been previously diagnosed with?
Chlamydia
Gonorrhea
Syphilis
Maternal MIDIS ID number (if applicable):
Infant MIDIS ID number (if applicable):
Question:
Please provide the name of the case:
First Name
Last Name
What is the case's date of birth:
-
Month
-
Day
Year
Date
What states are you requesting records from?
If possible, please provide any additional details (city, approximate date of records):
Please provide some background information/context to your question:
Submit
Should be Empty: