Nebraska Parkinson's Disease Registry
Reporting Forms

Please submit your information through our secure website, using the format below, or use the forms provided on this page.  I will need your email address to send you instructions on using the secure website.

Please use the following format for electronic files:

   MS WordPhysicians                 MS WordPharmacies

 

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, 2012:

  • Azilect
  • Carbidopa/levodopa (if prescribed for times other than evening or bedtime only)
  • Comtan
  • Mirapex (if prescribed for times other than evening or bedtime only)
  • Neupro
  • Requip (if prescribed for times other than evening or bedtime only)
  • Selegiline (except Emsam)
  • Stalevo

PLEASE NOTE: 

DO NOT report patients if the physician indicates that the drug is prescribed for RESTLESS LEG SYNDROME ONLY or if the drug is prescribed for EVENING OR BEDTIME USE ONLY.

If you have no patients to submit for your semi-annual report, please send an email to jill.krause@nebraska.gov and state that you have no patients to report, the time period, and your pharmacy name and address.

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 WordWord

  • Pharmacists Form

PDF PDF    MS WordWord

  • Self-Report Form

PDF PDF    MS WordWord

 

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which can be downloaded for free from Adobe Systems, Inc.


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