TEXAS DEPARTMENT OF STATE HEALTH SERVICES

Loading...

TEXAS DEPARTMENT OF STATE HEALTH SERVICES P.O. Box 149347 • Austin, Texas 78714-9347 • 1-888-963-7111

F14-13561 November 2014

Request for Release of An Individual’s Newborn Screening Specimens All requests for release of individual residual newborn screening specimens for further testing related to the child in question must be approved by DSHS Laboratory Management and, if necessary, DSHS Office of General Counsel.

Requirements for Release of Specimens to Physicians or other Healthcare Providers for Further Testing   

A completed Request for Release of An Individual’s Newborn Screening Specimens form (page 2). A completed Parent Consent Form for Release of DSHS Newborn Screening Specimen (page 3) A preferred courier for shipment of the specimens, with associated courier account #. A faxed or emailed prepaid shipping label is sufficient.

Requirements for Release of Specimens to Medical Examiners   

A completed Request for Release of An Individual’s Newborn Screening Specimens form (page 2). Formally request release under Texas Health & Safety Code Sec. 33.018(b)(4) by checking the box on page 2 related to a medical examiner conducting an autopsy/inquest of a child as described in that statutory provision. A preferred courier for shipment of the specimens, with associated courier account #. A faxed or emailed prepaid shipping label is sufficient.

Overview of Request Review Process 1.

Requestor completes the Request for Release of An Individual’s Newborn Screening Specimens form (page 2).

2.

Requestor submits request form (and parental consent if required) by email to [email protected], or faxes to 512-776-7712 or 512-776-2594.

3.

DSHS program contact reviews request. The DSHS program contact will serve as the requestor’s point of contact throughout the process.

4.

If the request meets the requirements, it will be approved. If the requirements are not met, the DSHS program contact will notify requestor with information on non-acceptance of request. The DSHS program contact may consult the DSHS Office of General Counsel for assistance in assessing the request.

5.

If request is approved, the requested specimen(s) will be shipped to the recipient identified in the request form, by means of the requestor’s preferred courier. The DSHS program contact will notify requestor of approval and shipment.

More Information  Questions: o Email DSHS Newborn Screening Laboratory: [email protected] o or Call: 1-888-963-7111 x 7585 or x 2471.  Fax completed forms to: 512-776-7712 or 512-776-2594.

1

TEXAS DEPARTMENT OF STATE HEALTH SERVICES P.O. Box 149347 • Austin, Texas 78714-9347 • 1-888-963-7111

F14-13561 November 2014

Request for Release of An Individual’s Newborn Screening Specimens *Required Field

Name and Title*:

Requestor

Facility Name: Mailing Address*: City, State, Zip*: Telephone #*: Email Address*: Full Name of Child*:

Child’s Information

Child’s Date of Birth*:

Request Details

Purpose of Request* (please be specific):

DSHS Lab Specimen #(s) Full Name of Mother: Mother’s SSN Mother’s Address & City:

Check which newborn screening blood spot card(s) you would like to be released for the child listed above*. (Only a portion of the blood spot card(s) may be released) 

st

1 screen NBS blood spot only



nd

2 NBS blood spot only



st

nd

1 and 2 NBS blood spots

Name and Title*:

Shipment Details

Mailing Address*: City, State, Zip*: Telephone #*: Additional Pertinent Patient Information Requested: Courier Acct # A faxed or emailed prepaid shipping label is acceptable*:

Preferred Courier for shipment of specimen(s) (UPS, FedEx, etc.)*:

Medical Examiners

In addition to completion of the form, please check the box below ONLY if you are a medical examiner:



Pursuant to Texas Health and Safety Code, Chapter 33, Section 33.018(b)(4) and as a medical examiner, I request a portion of the newborn screening dried blood spot card(s) for the child identified above for further testing.

Signature (Requestor)

Date

2

TEXAS DEPARTMENT OF STATE HEALTH SERVICES P.O. Box 149347 • Austin, Texas 78714-9347 • 1-888-963-7111

F14-13561 November 2014

Parent Consent Form for Release of DSHS Newborn Screening Specimen

Parent, Managing Conservator or Guardian, please fill out completely, sign and submit the form below. * Required Field I, (please print full name) hereby certify that I am the  Parent,  Managing Conservator, or  Legal Guardian (check one) of the child identified below. I further certify that there is no court order in effect which restricts my legal ability to make this request. In this capacity, I request and authorize DSHS to release: Check one*:

Release to the following physician or other healthcare provider*:

st

Name:

nd

Address:



1 newborn screen blood spot only



2 newborn screen blood spot only



Blood spots from the 1 and 2 newborn screen

st

nd

Only a portion of the blood spot card(s) may be released.

City, State, Zip

The purpose of this request for release* (please explain intended use):

Full Name of Child* (please print):

Child’s Date of Birth*:

Date(s) of Specimen Collection: DSHS Lab Specimen Number(s): Full Name of Mother* (please print): Mother’s Telephone Number: Mother’s Address: City, State, Zip Code:

Additional pertinent information.

Contact telephone # and email address:

Signature

Date

Submit completed form by mail, fax or scan and email to: Texas Department of State Health Services Newborn Screening Laboratory, MC 1947 PO Box 149347 Austin, Texas 78714-9347

Fax:

(512) 776-7712

Email:

[email protected]

For additional information, visit the Texas DSHS Newborn Screening web site at http://www.dshs.state.tx.us/lab/newbornscreening.shtm , or call 1-888-963-7111 ext. 7585 with any questions. 3

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS P.O. Box 149347 • Austin, Texas 78714-9347 • 1-888-963-7111

F14-13561 Noviembre de 2014

Formulario de consentimiento de los padres para divulgar las muestras para las pruebas de detección temprana a recién nacidos del DSHS Al padre o madre, custodio administrador o tutor: por favor, rellene todo el formulario siguiente, fírmelo y entréguelo. * Campo obligatorio (por favor, escriba en letra de molde el nombre Yo, completo) por este medio certifico que soy el  padre o madre,  custodio administrador o  tutor legal (marque uno) del niño identificado a continuación. Certifico además que no hay ninguna orden judicial en vigor que restrinja mi capacidad legal para hacer esta petición. En dicha capacidad, solicito y autorizo al DSHS a divulgar lo siguiente: Marque uno*: Divulgar al médico u otro proveedor de servicios de salud siguientes*: Solo la primera prueba de detección temprana Nombre: I  por gota de sangre a recién nacidos Solo la segunda prueba de detección temprana  Domicilio: por gota de sangre a recién nacidos Las gotas de sangre de la primera y segunda  pruebas de detección temprana a recién nacidos Solo se puede divulgar una parte de la tarjeta de Ciudad, estado y código postal recogida de gotas de sangre. El propósito de esta solicitud de divulgación*(por favor, explique cuál es el propósito de su uso):

Nombre completo del niño* (por favor, escriba en letra de molde):

Fecha de nacimiento del niño*:

Fechas de obtención de las muestras: Número(s) de identificación de la(s) muestra(s) del DSHS laboratorio: Nombre completo de la madre* (por favor, escriba en letra de molde): Número telefónico de la madre: Domicilio de la madre: Ciudad, estado y código postal:

Información adicional pertinente.

Número telefónico y correo electrónico del contacto:

Firma

Fecha

Envíe el formulario completado por correo postal o fax, o escanéelo y mándelo por correo electrónico a: Texas Department of State Health Services Fax: (512) 776-7712 Newborn Screening Laboratory, MC 1947 Correo PO Box 149347 [email protected] electrónico: Austin, Texas 78714-9347 Para obtener información adicional, visite el sitio web del DSHS de Texas para las pruebas de detección temprana a recién nacidos en http://www.dshs.state.tx.us/lab/newbornscreening.shtm , o llame al 1-888-963-7111, extensión 7585, si tiene alguna pregunta. 4

Loading...

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

TEXAS DEPARTMENT OF STATE HEALTH SERVICES P.O. Box 149347 • Austin, Texas 78714-9347 • 1-888-963-7111 F14-13561 November 2014 Request for Release of...

205KB Sizes 2 Downloads 23 Views

Recommend Documents

Vacúnese - Texas Department of State Health Services
¿Se debe vacunar a todos los niños? La vacuna contra la gripe no está aprobada para ser usada en niños menores de 6

2012 health media catalog - Texas Department of State Health Services
Mar 18, 2004 - Media items are in great demand so it is extremely important to return them on the scheduled date. Any bo

2011 health media catalog - Texas Department of State Health Services
Mar 18, 2004 - Borrowers will be billed for any lost or damaged media. Returning Media. Return items on or before the sc

2012 health media catalog - Texas Department of State Health Services
Mar 18, 2004 - of attorney. It discusses both medical and emotional choices to be made about future care. While emphasiz

Chapter 133 - Texas Department of State Health Services
authorized by the Board of Nurse Examiners for the State of Texas to practice as a nurse .... (ii) a hospital for which

DSHS Grand Rounds - Texas Department of State Health Services
Healthy Texas Babies: Antenatal. Glucocorticoid Therapy,. Past, Present, and Future. Donald J. Dudley, M.D.. Division of

Hechos que debe saber - Texas Department of State Health Services
tratamiento a temprana etapa puede ayudar a retrasar el desarrollo del SIDA. Usted también puede tomar medidas para evi

Basic Nutrition Module.indb - Texas Department of State Health Services
Basic Nutrition. Module. DEPARTMENT OF STATE HEALTH SERVICES • NUTRITION SERVICES SECTION. Stock No. 13-33. August 200

interim formulary update - Texas Department of State Health Services
Nov 19, 2014 - Tablet. Suspension, oral. Dicyclomine. Bentyl®. Capsule: 20 mg. Tablet: 10 mg. Capsule: 10 mg. Injection

Establishments by Grant Type - Texas Department of State Health
79706 Midland. 432-686-8123. TX-0917. Processing. Only. Jimenez Meat Market. 2010 Railroad Street. Odessa. TX. 79761 Ect