Form IOCI15-337 "Parent/Individual Consent and Authorization to Release Newborn Metabolic Screening Results" - Illinois

What Is Form IOCI15-337?

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

Form Details:

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Download a fillable version of Form IOCI15-337 by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

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Download Form IOCI15-337 "Parent/Individual Consent and Authorization to Release Newborn Metabolic Screening Results" - Illinois

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Parent/Individual Consent and Authorization
State of Illinois
Illinois Department of Public Health
to Release Newborn Metabolic Screening Results
Include with this request payment of $25 by check or money order payable to Illinois Department of Public Health.
Do not send cash. Cash payments will be returned and will delay processing your request. Allow 10 business days to
process request. Note this form must be notarized.
Child’s Name _________________________________ Mother’s Name at Birth _________________________________
Child’s Date of Birth _______________ Gender _____________ Birth Hospital _________________________________
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
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 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 identified above.
_________________________________________________________
__________________________
Signature of Parent or Guardian if child is less than 18 years of age
Date
_________________________________________________________
__________________________
Signature of Individual if 18 years of age or older
Date
State of Illinois
County of ________________________________________________
Signed (or subscribed or attested) before me on ___________ (date) by
__________________________________________ (name of person).
For Internal Use Only
Date Received ______________________
(Seal)
Check/Money Order # ________________
Received by_____________/___________
_________________________________________________________
Signature of notary public
IOCI 15-337
Parent/Individual Consent and Authorization
State of Illinois
Illinois Department of Public Health
to Release Newborn Metabolic Screening Results
Include with this request payment of $25 by check or money order payable to Illinois Department of Public Health.
Do not send cash. Cash payments will be returned and will delay processing your request. Allow 10 business days to
process request. Note this form must be notarized.
Child’s Name _________________________________ Mother’s Name at Birth _________________________________
Child’s Date of Birth _______________ Gender _____________ Birth Hospital _________________________________
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
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 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 identified above.
_________________________________________________________
__________________________
Signature of Parent or Guardian if child is less than 18 years of age
Date
_________________________________________________________
__________________________
Signature of Individual if 18 years of age or older
Date
State of Illinois
County of ________________________________________________
Signed (or subscribed or attested) before me on ___________ (date) by
__________________________________________ (name of person).
For Internal Use Only
Date Received ______________________
(Seal)
Check/Money Order # ________________
Received by_____________/___________
_________________________________________________________
Signature of notary public
IOCI 15-337