Form CDPH4410 "Parent Request to Have Newborn Blood Specimen Card Destroyed" - California

What Is Form CDPH4410?

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, 2018;
  • 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 CDPH4410 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 CDPH4410 "Parent Request to Have Newborn Blood Specimen Card Destroyed" - California

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State of California—Health and Human Services Agency
California Department of Public Health
PARENT REQUEST TO HAVE
NEWBORN BLOOD SPECIMEN CARD DESTROYED
If mother is unable to sign, please enclose child’s state-issued birth certificate with official seal.
(It will be returned to parent after it has been reviewed.)
Parent or Parents Making the Request:
Mother's Full Name
(including maiden name):
________________________________________________
Mother’s Date of Birth:
_____________________
Mother’s e-mail address:
________________________________________________
Father’s Name (Last, First): ________________________________________________
Father’s e-mail address:
________________________________________________
Child’s Information:
Newborn’s Name (Last, First): ______________________________________________
Date of Birth (mm/dd/yyyy): _____________________ Gender:
Male
Female
Hospital of Birth: _________________________________________________________
Address of child at time of birth:_____________________________________________
__________________________________________________
Current Mailing Address:
______________________________________________
(if different from above)
______________________________________________
Phone: (
) _____ - ______
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.
Mother’s Signature: ________________________________________ Date: _____________
Father’s Signature: _________________________________________ Date: _____________
(Parent or Legal Guardian should sign only if request is for a minor under 18 years of age)
Mail completed form to:
California Biobank Program Coordinator
CDPH – GDSP
850 Marina Bay Pkwy., F175, MS 82 00
Print
Richmond, CA 94804
e-mail:
CaliforniaBiobank@cdph.ca.gov
Genetic Disease Screening Program
(510) 412-1500
FAX (510) 412-1547
GDSP Homepage
CDPH 4410 (02/18)
State of California—Health and Human Services Agency
California Department of Public Health
PARENT REQUEST TO HAVE
NEWBORN BLOOD SPECIMEN CARD DESTROYED
If mother is unable to sign, please enclose child’s state-issued birth certificate with official seal.
(It will be returned to parent after it has been reviewed.)
Parent or Parents Making the Request:
Mother's Full Name
(including maiden name):
________________________________________________
Mother’s Date of Birth:
_____________________
Mother’s e-mail address:
________________________________________________
Father’s Name (Last, First): ________________________________________________
Father’s e-mail address:
________________________________________________
Child’s Information:
Newborn’s Name (Last, First): ______________________________________________
Date of Birth (mm/dd/yyyy): _____________________ Gender:
Male
Female
Hospital of Birth: _________________________________________________________
Address of child at time of birth:_____________________________________________
__________________________________________________
Current Mailing Address:
______________________________________________
(if different from above)
______________________________________________
Phone: (
) _____ - ______
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.
Mother’s Signature: ________________________________________ Date: _____________
Father’s Signature: _________________________________________ Date: _____________
(Parent or Legal Guardian should sign only if request is for a minor under 18 years of age)
Mail completed form to:
California Biobank Program Coordinator
CDPH – GDSP
850 Marina Bay Pkwy., F175, MS 82 00
Print
Richmond, CA 94804
e-mail:
CaliforniaBiobank@cdph.ca.gov
Genetic Disease Screening Program
(510) 412-1500
FAX (510) 412-1547
GDSP Homepage
CDPH 4410 (02/18)