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Remove Disease specifies

You attempt to counteract one disease afflicting the target.

Do you need to pick a specific instance of disease to remove? Or is it random/determined by GM/something else?

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You don't need to

Remove disease is a very brief spell, but by its Targets entry of "1 creature" it can be cast on any particular creature (regardless of the presence of a disease/diseases). If the creature is afflicted with a disease, the spell will attempt to counteract it.

As to what should happen when the spell is cast upon a creature with multiple diseases, that'd be up to GM discretion. It seems reasonable that the caster should be able to select a particular disease if they knew of it (or even just a particular symptom), otherwise if the spell treats their common cold instead of the magical super plague it seems like a weird outcome. But a GM might decide it's random or perhaps something like the highest-level disease afflicting the creature.

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