(1) If a resident of this state is diagnosed with Parkinson's disease or a related movement disorder within this state in the office of a physician licensed under the Uniform Credentialing Act, the physician shall file a report of the diagnosis and pertinent information with the department within sixty days after the diagnosis.

(2) An individual resident of this state who has been diagnosed with Parkinson's disease or a related movement disorder by a licensed physician may file a report with the department providing relevant information. The department shall provide for validation of individual reports.

(3) A report filed under this section shall contain the following information about the person diagnosed with Parkinson's disease or a related movement disorder:

(a) Name;

(b) Social security number;

(c) Date of birth;

(d) Gender;

(e) Address at time of diagnosis;

(f) Current address;

(g) Date of diagnosis;

(h) Physician;

(i) Identification of reporting source; and

(j) Any additional information the department demonstrates is reasonable to implement the Parkinson's Disease Registry Act.