Form CDPH4407 "Consent for Release of Dried Blood Specimen From Gdsp" - California

What Is Form CDPH4407?

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 June 1, 2014;
  • 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 CDPH4407 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 CDPH4407 "Consent for Release of Dried Blood Specimen From Gdsp" - California

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State of California—Health and Human Services Agency
California Department of Public Health
CONSENT FOR RELEASE OF DRIED BLOOD SPECIMEN FROM GDSP
The undersigned hereby authorizes the release of the Newborn Screening Specimen
from the records of the Genetic Disease Screening Program (GDSP).
FOR NEWBORN PATIENT
Name:
Gender:
Male
Female Twin:
Yes
No Date of Birth:
Hospital Of Birth:
Mother’s Full Name (including maiden name):
Mother’s Date of Birth:
Patient’s Address at Time of Birth:
RELEASE TO
Requestor Name:
Phone:
Requestor Email:
Ship Attention To:
Facility Name and Address:
Facility Phone:
Facility Fax #
:
REASON FOR REQUEST
This authorization will expire on (Enter Date): ___________________________________________.
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 at 850 Marina Bay Parkway, Richmond, CA 94804, as stated in our
privacy notice. Revocation of this consent does not eliminate your responsibilities for payment for services received.
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.
______________________________________________
____________________
(Parent/Patient/Legal Guardian Signature)
(Date)
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.
Please See Privacy Notification on Reverse
Genetic Disease Screening Program  Newborn Screening Program  Richmond, CA 94804
(510) 412-1500 ● (510) 412-1547 FAX
Website:
www.cdph.ca.gov/programs/nbs
E-mail questions to:
CaliforniaBiobank@cdph.ca.gov
CDPH 4407 (6/14)
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State of California—Health and Human Services Agency
California Department of Public Health
CONSENT FOR RELEASE OF DRIED BLOOD SPECIMEN FROM GDSP
The undersigned hereby authorizes the release of the Newborn Screening Specimen
from the records of the Genetic Disease Screening Program (GDSP).
FOR NEWBORN PATIENT
Name:
Gender:
Male
Female Twin:
Yes
No Date of Birth:
Hospital Of Birth:
Mother’s Full Name (including maiden name):
Mother’s Date of Birth:
Patient’s Address at Time of Birth:
RELEASE TO
Requestor Name:
Phone:
Requestor Email:
Ship Attention To:
Facility Name and Address:
Facility Phone:
Facility Fax #
:
REASON FOR REQUEST
This authorization will expire on (Enter Date): ___________________________________________.
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 at 850 Marina Bay Parkway, Richmond, CA 94804, as stated in our
privacy notice. Revocation of this consent does not eliminate your responsibilities for payment for services received.
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.
______________________________________________
____________________
(Parent/Patient/Legal Guardian Signature)
(Date)
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.
Please See Privacy Notification on Reverse
Genetic Disease Screening Program  Newborn Screening Program  Richmond, CA 94804
(510) 412-1500 ● (510) 412-1547 FAX
Website:
www.cdph.ca.gov/programs/nbs
E-mail questions to:
CaliforniaBiobank@cdph.ca.gov
CDPH 4407 (6/14)
NOTICE OF INFORMATION AND PRIVACY PRACTICES
California Department of Public Health (CDPH)
Genetic Disease Screening Program (GDSP)
The California Newborn Screening Program Note
Effective Date: June 2014
THIS NOTICE DESCRIBES HOW PERSONAL AND MEDICAL INFORMATION ABOUT
YOU OR YOUR NEWBORN MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Department’s Legal Duty
Federal and State laws restrict the use, maintenance, and disclosure of personal and
medical information obtained by a State agency and requires certain notices to
individuals whose information is maintained.
State laws include the California Information Practices Act (Civil Code 1798 et seq.),
Government Code Section 11015.5 and Health and Safety Code Section 124980. The
federal law is the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
42 USC 1320d-2(a) (2), and its regulations in Title 45 Code of Federal Regulations
Sections 160.100 et seq. In compliance with these laws, you and those providing
information are notified of the following.
Department Authority and Purpose for the Newborn Screening Program
The CDPH collects and maintains specimens and information related to newborn
screening as permitted in Health and Safety Code Sections 124980, 124977, 124991,
125000, 125001, 125025, and 125030. This information is collected electronically and
includes such things as your name, address, medical care given to you and your
newborn. Testing is required by law (Health and Safety Code Section 125000) and
regulations (17 CCR 6500 through 6510) and if the required information is not provided,
serious illness or permanent damage for affected newborns could result.
If you have religious objections to this testing, you may say “no” to the testing in writing
and sign a form advising you that your hospital, doctor, and clinic staff are not
responsible if your baby develops problems because those disorders were not identified
and treated early.
Uses and Disclosure of Health Information
The CDPH uses health information about you or your newborn for screening, to provide
health care services, to obtain payment for screening, for administrative purposes, and
to evaluate the quality of care that you or your newborn receives. Some of this
information is retained for as long as 21 years. The information will not be sold.
The law also allows the Department to use or give out newborn screening specimens
and/or general health information about you or your baby, for department-approved
studies, such as research related to preventing disease. The material will be provided,
without any personal identifying information. Researchers can only apply to receive
CDPH 4407 (6/14)
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the information if they have been approved by an institutional review board (IRB) and
meet all federal and state privacy law requirements.
The Department is authorized by law to charge approved researchers a fee to recover
all the expenses related to the research request (including data linkage, retrieval, data
processing, data entry, re-inventory, shipping of blood samples, and related data
management).
The Department reserves the right to change the terms of this notice and to make the
new notice provisions effective for all protected health information that it maintains. The
most current Privacy Notice can be found at the Newborn Screening Program website:
www.cdph.ca.gov/programs/nbs. You may request a copy of the current policies or
obtain more information about our privacy practices, by calling the numbers listed below
or consulting the Program website. You may also request a paper copy of this Notice.
This Privacy Notice can also be found at the website:
www.ca.gov/programs/pages/Privacyoffice.aspx.
Individual Rights and Access to Information
The Newborn Screening Program must have your written permission to use or give out
personal or health information about you for any reason that is not described in this
notice. You can revoke your authorization at any time, except if the Newborn Screening
Program has already acted because of your permission by contacting the Chief of the
Genetic Disease Screening Program at 850 Marina Bay Parkway, F175, Richmond, CA
94804.
You have the right to look at or receive a copy (you will be charged) of your or your
newborn’s health information and receive a list of instances where we have disclosed
health information about you or your newborn for reasons other than payment for
screening or related administrative purposes.
You have a right to ask that the Newborn Screening Program contact you only in
writing, or at a different address, post office box, or telephone number. Newborn
Screening Program
will contact you the way you have asked if this is necessary to keep
you safe.
You have a right to ask the
Newborn Screening Program
not to use or share your or
your newborn’s information and/or specimen in the ways listed in this notice. However,
we may not be able to comply with your request.
You have a right to have information in your or your child’s records changed if
information is missing or you believe the information is incorrect.
Complaints
We will let you know promptly if a breach occurs that may have compromised the
privacy or security of your information. If you believe that we have not protected your
privacy or have violated any of your rights and wish to file a complaint, please call or
CDPH 4407 (6/14)
Page 3 of 4
write to the: Privacy Officer, CA Department of Public Health, P.O. Box 997377, MS
0506, Sacramento, CA 95899-7377, (916) 440-7671 or (877) 421-9634 TTY/TDD.
You may also contact the United States Department of Health and Human Services,
Attention: Regional Manager, Office for Civil Rights at 90 7th Street, Suite 4-100, San
Francisco, CA 94103, telephone (800) 368-1019, or the U.S. Office of Civil Rights at
866-OCR-PRIV (866-627-7748) or 866-788-4989 TTY.
The Department cannot take away your health care benefits or any other protected
rights in any way if you choose to file a complaint or use any of the privacy rights in this
notice.
Department Contact
The information on this form is maintained by the California Department of Public
Health, Genetic Disease Screening Program. Please address correspondence to the
Chief of the Genetic Disease Screening Program, 850 Marina Bay Parkway, F175, Mail
Stop 8200, Richmond, California, 94804 (510-412-1502).
Electronic Copies of this Notice: To get a copy of this notice in an electronic format
call or write to:
Chief, Genetic Disease Screening Program
850 Marina Bay Pkwy, F175, Mail Stop 8200, Richmond, CA 94804
Phone: 510-412-1502 Relay Operator 711/1-800-735-2929
CDPH 4407 (6/14)
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