A. A physician in this state who provides informed consent information regarding abortion pursuant to section 36-2153 or performs fetal ultrasound imaging and auscultation of fetal heart tone services pursuant to section 36-2156 or who delegates to a person authorized by section 36-2153 or 36-2156 the duty to provide the information or services required by those sections shall submit to the department of health services on a form prescribed by the department a report that includes the following information:

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1. The number of women to whom the physician provided the information described in section 36-2153, subsection A, paragraph 1, and, of those women, the number provided in the capacity of a referring physician and the number provided in the capacity of a physician who is to perform the abortion.

2. The number of women to whom the physician, physician assistant, nurse, psychologist or licensed behavioral health professional provided the information described in section 36-2153, subsection A, paragraph 2, and, of those women, the number provided in the capacity of a referring physician and the number provided in the capacity of a physician who is to perform the abortion, and, of each of those numbers, the number provided by the physician and the number provided by a physician assistant, nurse, psychologist or licensed behavioral health professional.

3. The number of women for whom the physician or qualified person working in conjunction with the physician performed fetal ultrasound imaging and auscultation of fetal heart tone services described in section 36-2156, subsection A, paragraph 1, and, of those numbers, the number provided in the capacity of a referring physician and the number provided in the capacity of a physician who is to perform the abortion, and, of each of those numbers, the number provided by the physician and the number provided by a qualified person working in conjunction with the physician.

4. The number of abortions performed by the physician in which information required by sections 36-2153 and 36-2156 to be provided at least twenty-four hours before the abortion was not provided because a medical emergency compelled the performance of an abortion to avert the woman’s death and the number of abortions in which this required information was not provided because a medical emergency compelled the performance of an abortion to avert substantial and irreversible impairment of a major bodily function of the woman.

B. The report may not identify the individual patient by name or include any other information or identifier that would make it possible to identify, in any manner or under any circumstances, a woman who has obtained or sought to obtain an abortion.

C. The report shall be signed by the physician who provided to the woman the information required by section 36-2153, subsection A, paragraph 1 or the physician who delegated the duty to another person authorized by law to provide to the woman the information required by section 36-2153, subsection A, paragraph 2 or section 36-2156, subsection A, paragraph 1. The form may be signed electronically and shall indicate that the physician who signs the report is attesting that the information in the report is correct to the best of the physician’s knowledge. The physician must transmit the report to the department within fifteen days after the last day of each reporting month.

D. Any report filed pursuant to this section shall be filed electronically at an internet website that is designated by the department unless the person required to file the report applies for a waiver from electronic reporting by submitting a written request to the department.