(1) If a person with brain or head injury is treated in this state in the office of a physician or psychologist licensed to practice in this state but is not admitted to a hospital within this state, the treating physician or psychologist shall provide a report of such injury to the department within thirty days after such treatment and identification of the person sustaining such injury.

(2) If a person with brain or head injury is admitted to or treated at a hospital or a rehabilitation center located within a hospital in this state, such hospital or rehabilitation center shall provide a report of such injury to the department within thirty days after the discharge of such person from the hospital or rehabilitation center.

(3) A report provided under this section shall contain the following information about the person who has sustained the brain or head injury, if known:

(a) Name;

(b) Date of birth;

(c) Gender;

(d) Residence;

(e) Date of the injury;

(f) Final diagnosis or classification of the injury according to the International Classification of Disease, Clinical Modification Coding System of the World Health Organization, as adopted by the department;

(g) Cause of the injury and, if practicable, whether the injury resulted from an accident involving the use of alcohol;

(h) Place or site of occurrence of the injury;

(i) Identification of the reporting source;

(j) Disposition upon discharge;

(k) Payor source; and

(l) Any additional information the department deems necessary and appropriate to carry out the purposes of the Brain Injury Registry Act.