"Health Care Provider Consent and Authorization to Release Newborn Screening Results" - Illinois

Health Care Provider Consent and Authorization to Release Newborn Screening Results is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

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Download "Health Care Provider Consent and Authorization to Release Newborn Screening Results" - Illinois

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Health Care Provider Consent and Authorization
State of Illinois
Illinois Department of Public Health
to Release Newborn Screening Results
Newborn Blood Spot Metabolic Result Requested
Newborn Hearing Screening Result Requested
The following information is required in order to release newborn screening results:
Child’s Name _________________________________ Mother’s Name at Birth _________________________________
Child’s Date of Birth _______________ Gender _____________ Birth Hospital _________________________________
Medical provider requesting newborn screening results _____________________________________________________
How would you like to receive this information:
Mail
Fax
Electronic
Address/e-mail where results are to be sent:
Fax number where results are to be sent:
_____________________________
Phone number where you can be reached: _____________________________
Send this form to:
Illinois Department of Public Health
Newborn Screening Program
535 W. Jefferson St., 2nd Floor
Springfield, IL 62761
Phone: 217-785-8101
Fax: 217-557-5396
DPH.newbornscreening@Illinois.gov
The purpose of the Illinois Department of Public Health Newborn Screening Program is to identify infants at risk for certain
congenital conditions and in need of more definitive testing. As with any laboratory test, false positive or false negative
results are possible. Newborn screening test results are insufficient information on which to base diagnosis or treatment.
I certify the child listed above is my patient and hereby grant permission to the Illinois Department of Public Health Newborn
Screening Program to release the newborn screening record, including laboratory test reports of the child stated above,
for diagnosis and treatment purposes only.
_________________________________________________________
__________________________
Signature of Health Care Provider
Date
IOCI 15-337
Health Care Provider Consent and Authorization
State of Illinois
Illinois Department of Public Health
to Release Newborn Screening Results
Newborn Blood Spot Metabolic Result Requested
Newborn Hearing Screening Result Requested
The following information is required in order to release newborn screening results:
Child’s Name _________________________________ Mother’s Name at Birth _________________________________
Child’s Date of Birth _______________ Gender _____________ Birth Hospital _________________________________
Medical provider requesting newborn screening results _____________________________________________________
How would you like to receive this information:
Mail
Fax
Electronic
Address/e-mail where results are to be sent:
Fax number where results are to be sent:
_____________________________
Phone number where you can be reached: _____________________________
Send this form to:
Illinois Department of Public Health
Newborn Screening Program
535 W. Jefferson St., 2nd Floor
Springfield, IL 62761
Phone: 217-785-8101
Fax: 217-557-5396
DPH.newbornscreening@Illinois.gov
The purpose of the Illinois Department of Public Health Newborn Screening Program is to identify infants at risk for certain
congenital conditions and in need of more definitive testing. As with any laboratory test, false positive or false negative
results are possible. Newborn screening test results are insufficient information on which to base diagnosis or treatment.
I certify the child listed above is my patient and hereby grant permission to the Illinois Department of Public Health Newborn
Screening Program to release the newborn screening record, including laboratory test reports of the child stated above,
for diagnosis and treatment purposes only.
_________________________________________________________
__________________________
Signature of Health Care Provider
Date
IOCI 15-337