(a) A physician who has primary responsibility for treating a veteran who believes he may have been exposed to chemical defoliants or herbicides or other causative agents, including but not limited to Agent Orange, while serving in the armed forces of the United States shall, at the request of the veteran, submit a report to the department on a form provided by the department. If there is no physician having primary responsibility for treating the veteran, the hospital treating the veteran shall, at the request of the veteran, submit the report to the department.

(b) The form provided by the department to the physician shall request the following information:

(1) Symptoms of the veteran which may be related to exposure to a chemical defoliant or herbicide or other causative agent, including Agent Orange;

(2) Diagnosis of the veteran; and

(3) Methods of treatment prescribed.

(c) The department may require the veteran to provide such other information as determined by the commissioner.