Every physician licensed by the department of health attending on or called in to evaluate a patient whom he or she believes to be suffering from an occupational disease or condition identified by the department of health in regulation as a reportable occupational disease shall within thirty (30) days of that attendance or evaluation send to the department of health a report, on a form acceptable to the director of health, stating:
(1) Name, address, and occupation of patient.
(2) Name, address, and business of employer.
(3) Nature of disease.
(4) Any other information that may be reasonably required by the department of health.