Every physician that provides treatment or rehabilitation services to a person addicted to or dependent upon drugs shall each quarter of every year, commencing July 1, 1971, make a statistical report to the director of the department of health and welfare or his designee in such form and manner as the director of the department of health and welfare shall prescribe for each such person treated or to whom rehabilitation services were provided during the preceding quarter. The form of the report prescribed shall be furnished by the director of the department of health and welfare and be so designated that a carbon copy shall be sent quarterly to the director of the Idaho state police and the state board of pharmacy; the report shall include the doctor’s signature. The name or address of any person treated or to whom rehabilitation services were provided shall not be reported.