Form CDPH4453 "Request for California Prenatal Screening Program Supplies" - California

What Is Form CDPH4453?

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 January 1, 2017;
  • 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 CDPH4453 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 CDPH4453 "Request for California Prenatal Screening Program Supplies" - California

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California Department of Public Health
State of California Health and Human Services Agency
Genetic Disease Screening Program
California Prenatal Screening Program
REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES
To Order Supplies:
Mailing address:
Toll-free phone
(877) 984-8450
California Department of Public Health
:
Toll-free fax
(877) 984-8650
:
Prenatal Screening Program Supplies
email:PNSsupplies@cdph.ca.gov
850 Marina Bay Parkway, F175
Richmond, CA 94804-6403
Clinician’s license number
Last name
First name
Organization/department
Telephone number
Fax number
State and Zip Code
City
Address (number, street, suite number)
Attention
(Optional) e-mail address Date
Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO
Order “tubes only” if using other courier service.
Please use one tray, one pouch, and one box to send one or two specimens if they
Request for 6 mo supply
are drawn the same day.
First Trimester Prenatal Screening Forms (blue edge)
Second Trimester Prenatal Screening Forms (green edge)
Blood Shipping Kit:
Kits contain one 3.5ml serum separator tube (SST),
one tray, one pouch and one box to mail the blood specimen in.
For individual items, CIRCLE as needed:
TUBES / TRAYS / POUCHES / BOXES
Indicate (below) the number of booklets/pamphlets needed in each language: Booklets not
available in gray shaded areas
Chinese Vietnamese Korean
English
Spanish
Prenatal Diagnosis of Birth Defects
Patient Booklet (includes Consent Form)
“Easy -to-Read” Pamphlet
Prenatal Diagnosis of Birth Defects
CDPH 4453 (1/17)
California Department of Public Health
State of California Health and Human Services Agency
Genetic Disease Screening Program
California Prenatal Screening Program
REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES
To Order Supplies:
Mailing address:
Toll-free phone
(877) 984-8450
California Department of Public Health
:
Toll-free fax
(877) 984-8650
:
Prenatal Screening Program Supplies
email:PNSsupplies@cdph.ca.gov
850 Marina Bay Parkway, F175
Richmond, CA 94804-6403
Clinician’s license number
Last name
First name
Organization/department
Telephone number
Fax number
State and Zip Code
City
Address (number, street, suite number)
Attention
(Optional) e-mail address Date
Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO
Order “tubes only” if using other courier service.
Please use one tray, one pouch, and one box to send one or two specimens if they
Request for 6 mo supply
are drawn the same day.
First Trimester Prenatal Screening Forms (blue edge)
Second Trimester Prenatal Screening Forms (green edge)
Blood Shipping Kit:
Kits contain one 3.5ml serum separator tube (SST),
one tray, one pouch and one box to mail the blood specimen in.
For individual items, CIRCLE as needed:
TUBES / TRAYS / POUCHES / BOXES
Indicate (below) the number of booklets/pamphlets needed in each language: Booklets not
available in gray shaded areas
Chinese Vietnamese Korean
English
Spanish
Prenatal Diagnosis of Birth Defects
Patient Booklet (includes Consent Form)
“Easy -to-Read” Pamphlet
Prenatal Diagnosis of Birth Defects
CDPH 4453 (1/17)
Indicate (below) the number of booklets/pamphlets needed in each language: Booklets not
available in gray shaded areas
English
Spanish
Folate pamphlet “Before and During"
Provider Handbook (One per clinician)
Screen Positive (Distributed to Prenatal Diagnosis Centers for women with screen positive results)
First Trimester
Down Syndrome
Second Trimester
First Trimester
Trisomy 18
Second Trimester
How many NEW OB
Neural Tube Defects or Ab.Wall Defects
patients per month:
Smith-Lemli - Opitz Syndrome
Large Nuchal Translucency
PREGNANCY CALCULATION WHEEL
Important Information About the
Newborn Screening Test (English &
Spanish combined)
All Prenatal Screening supplies are the property of the State of California. Other use is strictly
prohibited.
Allow 2-4 Weeks for Delivery
For Questions and Concerns: CALL (510) 412-1441
CDPH 4453 (1/17)
REQUE ST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES
FOR LABORATORIES AND DRAW STATIONS ONLY
(Clinicians Use First Two Pages)
Mailing address:
To Order Supplies:
California Department of Public
Toll-free phone: (877) 984 -8450
Health Prenatal Screening Progra m
Toll-free fax: (877 ) 984-8650
Supplies 850 Marina Bay Parkway,
email:PNSsupplies@cdph.ca.gov
F175 Richmond, CA 94804 -6403
Name of laboratory/draw station
Fax number
Telephone number
(
)
(
)
State
Organization/department cont...
Organization/department
City
ZIP code
Address (number, street, suite number)
Attention
e-mail address for confirmation
Date
Use Blood Shipping Kits for specimens sent U.S. mail or GSO. Order “tubes only” if using other courier service.
Use one tray, one pouch, one box to send one or two specimens if they are drawn the same day.
Quantity Requested
(Enough for 6-Month)
Blood Shipping Kit contain: one 3.5ml blood separator tube (SST), one tray,
one pouch, one box to mail the blood specimen in.
For individual items, circle as needed:TUBES/ TRAYS/ POUCHES / BOXES
1. Prenatal Care Provider will complete Part A of the Prenatal Screening Test Request Form.
2. Phlebotomist at laboratory/draw station must complete Part B of the Prenatal Screening Test
Request Form.
3. Please pho tocopy this supply form for future requests.
The California Prenatal Screening Program bills patients directly for the Program fee. Laboratories
may bill patients separately a reasonable fee for drawing and handling
blood specimens, taking into account that the State Program provides tubes and
mailing supplies free of charge to laboratories and draw stations, as well as clinicians.
Reminder: Use only Beckton-Dickinson 3.5ml Serum Separator Tubes (SST) with a
gold “vacutainer” top as supplied by the Prenatal Screening Program. Screening test
results are based upon calibration for these tubes only .
Important Note: First Trimester specimens MUST be centrifuged or they cannot be
analyzed.
Program information and materials may be found on the Program website at :
www.cdph.ca.gov/Programs/CFH/DGDS/Pages/pns/orderingsupplies.aspx
All Prenatal Screening supplies are the property of the State of California. Other use is strictly prohibited.
Allow 2-4 Weeks for Delivery For Questions and Concerns: CALL (510) 412-1441
CDPH 4453 (1/17)
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