Form CDPH4400 "NCAA Student Athlete Request for Newborn Screening Hemoglobin Results" - California

What Is Form CDPH4400?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH4400 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH4400 "NCAA Student Athlete Request for Newborn Screening Hemoglobin Results" - California

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of California – Health and Human Services Agency
State
California Department of Public Health
Genetic Disease Screening Program
Submit Online
NCAA Student Athlete Request for Newborn Screening Hemoglobin Results
STUDENT’S INFORMATION
First Name
Last Name
Date of Birth (mm/dd/yyyy)
GENDER
MALE
FEMALE
Were You Part of a Multiple Birth? (in other
If yes, where were you in the birth order?
words, were you a twin, triplet or more?)
(usually A, B, C or 1, 2, 3…etc)
NO
YES
Hospital of Birth
City Where Birth Hospital is Located
BIRTH MOTHER’S INFORMATION
First Name
Last Name
Date of Birth (mm/dd/yyyy)
Maiden Name
Other Names Used
City Mother Lived in at Time of Student’s Birth
SIGNATURE
You do not need an inked signature if you choose to submit your request electronically. Your printed
name, email address and today’s date constitute your digital signature. The undersigned hereby
authorizes the release of the Newborn Screening Hemoglobin test results from the records of the
California Genetic Disease Screening Program. Authorization for release expires one year from date
signed. Must be signed by student if 18 years of age or older. Parent or legal guardian should sign only if
student is under the age of 18 years.
Signature (student – if over 18, parent/guardian – if student under 18)
Your Printed Name
Date (mm/dd/yyyy)
Best email address for us to send you your results
Best phone number to reach you at
CDPH Genetic Disease Screening Program (GDSP) – Newborn Screening Program
850 Marina Bay Parkway, Room F-175, Richmond, CA 94804
Information can be found at:
CDPH Newborn Screening Program
E-mail questions to: NCAANBSResults@cdph.ca.gov
CDPH 4400 (2/20)
of California – Health and Human Services Agency
State
California Department of Public Health
Genetic Disease Screening Program
Submit Online
NCAA Student Athlete Request for Newborn Screening Hemoglobin Results
STUDENT’S INFORMATION
First Name
Last Name
Date of Birth (mm/dd/yyyy)
GENDER
MALE
FEMALE
Were You Part of a Multiple Birth? (in other
If yes, where were you in the birth order?
words, were you a twin, triplet or more?)
(usually A, B, C or 1, 2, 3…etc)
NO
YES
Hospital of Birth
City Where Birth Hospital is Located
BIRTH MOTHER’S INFORMATION
First Name
Last Name
Date of Birth (mm/dd/yyyy)
Maiden Name
Other Names Used
City Mother Lived in at Time of Student’s Birth
SIGNATURE
You do not need an inked signature if you choose to submit your request electronically. Your printed
name, email address and today’s date constitute your digital signature. The undersigned hereby
authorizes the release of the Newborn Screening Hemoglobin test results from the records of the
California Genetic Disease Screening Program. Authorization for release expires one year from date
signed. Must be signed by student if 18 years of age or older. Parent or legal guardian should sign only if
student is under the age of 18 years.
Signature (student – if over 18, parent/guardian – if student under 18)
Your Printed Name
Date (mm/dd/yyyy)
Best email address for us to send you your results
Best phone number to reach you at
CDPH Genetic Disease Screening Program (GDSP) – Newborn Screening Program
850 Marina Bay Parkway, Room F-175, Richmond, CA 94804
Information can be found at:
CDPH Newborn Screening Program
E-mail questions to: NCAANBSResults@cdph.ca.gov
CDPH 4400 (2/20)
NCAA Student Athlete Request for Newborn Screening Hemoglobin Results
Please Note:
• It can take up to 30 days to process your request. If you need your results
in less time, we recommend having a sickle cell test run by your physician
• Results are only available for California births after 2/26/1990
Adobe’s Acrobat Reader
You must have
to use this form.
Parents cannot request results for offspring 18 years or older.
Information on NCAA Athletes Request can be found at:
CDPH Newborn Screening Program
If unable to fill form out and submit electronically, please: Print form, fill out with clear BLOCK PRINT,
sign and return by mail or by email (JPG/PDF) to
NCAANBSResults@cdph.ca.gov
Print
You have the right to retain a copy of this consent. You have the right to revoke this consent at any
time by writing to:
Chief, Genetic Disease Screening Program
850 Marina Bay Parkway, F175, Richmond, CA 94804
The Genetic Disease Screening Program is not responsible for further disclosures of the information
by other parties that may result from complying with this consent.
I understand that any person who requests or obtains any record containing personal information
from the California Department of Public Health under false pretenses will be guilty of a misdemeanor
and fined up to $5,000 or imprisoned up to one year or both.
Privacy Notification
The Genetic Disease Screening Program (GDSP) is defined as a health care provider under HIPAA
and is a covered entity. GDSP is therefore required to distribute a Notice of Privacy Practice (NPP).
The collection and exchange of personal health information between covered providers for the
purpose of treatment, payment, or health care operations with GDSP and our agents in connection
with the newborn and prenatal screening programs is permitted by HIPAA and required by state law
without special authorization or Business Associates Agreements.
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