Form Inorg/Tox200 "Blood Lead Test Requisition" - Vermont

What Is Form Inorg/Tox200?

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

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Vermont Department of 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 printable version of Form Inorg/Tox200 by clicking the link below or browse more documents and templates provided by the Vermont Department of Health.

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Download Form Inorg/Tox200 "Blood Lead Test Requisition" - Vermont

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Vermont Department of Health Laboratory – Blood Lead Test Requisition
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Physical Address: 359 South Park Drive, Colchester VT 05446 ● (802) 338-4724 / (800) 660-9997 in VT only
All specimens must be labeled with matching patient name, date of birth and date of collection.
For Laboratory Use Only
VDH Lab Number/LIMS #
Submitter/Practice Information
Practice Name
Contact Person
Or VDH District Office
or Lead Designee
Address
Primary Care Practice
(for District Office purposes)
City/Town
State
Zip Code
Referring Physician
(Last Name/First Name)
Include credentials (MD, PA, etc.)
Telephone Number
Extension
NPI #
Patient Information
Last Name
First Name
MI
Date of Birth:
Gender:
Male
/
/
(
mm/dd/yyyy)
Female
Street Address:
Race
:
Ethnicity:
(check one)
African American or Black
Hispanic
NOT Hispanic
American Indian
Asian
Multiracial
Other
Unknown
Apt # or Unit #:
Other
Pacific Islander
Unknown
White
City/Town
Parent/Guardian Name (Last Name/First Name)
And Contact Phone #
State
Zip Code
Occupation (if patient is ≥ 16 years old)
Name of Employer (if applicable)
Specimen Information
Source
Date of Collection:
ICD-10 Code:
/
/
(
Blood Capillary
Blood Venous
mm/dd/yyyy)
Laboratory Test Requested
Blood Lead
Check if No Insurance
Billing Information
See Attached Sheet
Subscriber Name
Medicaid Number
Insurance Company Name
ID Number
Group Number
Secondary Insurance Company Name
ID Number
Group Number
Contact the Healthy Homes Lead Poisoning Prevention Program for lead education materials and clinical consultation or go to
www.healthvermont.gov/lead
FORM INSTRUCTIONS AND WEBSITE ADDRESS PROVIDED ON THE
BACK SIDE
Inorg/Tox 200 Rev 1 (02/2019)
Page 1of 2
Vermont Department of Health Laboratory – Blood Lead Test Requisition
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Physical Address: 359 South Park Drive, Colchester VT 05446 ● (802) 338-4724 / (800) 660-9997 in VT only
All specimens must be labeled with matching patient name, date of birth and date of collection.
For Laboratory Use Only
VDH Lab Number/LIMS #
Submitter/Practice Information
Practice Name
Contact Person
Or VDH District Office
or Lead Designee
Address
Primary Care Practice
(for District Office purposes)
City/Town
State
Zip Code
Referring Physician
(Last Name/First Name)
Include credentials (MD, PA, etc.)
Telephone Number
Extension
NPI #
Patient Information
Last Name
First Name
MI
Date of Birth:
Gender:
Male
/
/
(
mm/dd/yyyy)
Female
Street Address:
Race
:
Ethnicity:
(check one)
African American or Black
Hispanic
NOT Hispanic
American Indian
Asian
Multiracial
Other
Unknown
Apt # or Unit #:
Other
Pacific Islander
Unknown
White
City/Town
Parent/Guardian Name (Last Name/First Name)
And Contact Phone #
State
Zip Code
Occupation (if patient is ≥ 16 years old)
Name of Employer (if applicable)
Specimen Information
Source
Date of Collection:
ICD-10 Code:
/
/
(
Blood Capillary
Blood Venous
mm/dd/yyyy)
Laboratory Test Requested
Blood Lead
Check if No Insurance
Billing Information
See Attached Sheet
Subscriber Name
Medicaid Number
Insurance Company Name
ID Number
Group Number
Secondary Insurance Company Name
ID Number
Group Number
Contact the Healthy Homes Lead Poisoning Prevention Program for lead education materials and clinical consultation or go to
www.healthvermont.gov/lead
FORM INSTRUCTIONS AND WEBSITE ADDRESS PROVIDED ON THE
BACK SIDE
Inorg/Tox 200 Rev 1 (02/2019)
Page 1of 2
Vermont Department of Health Laboratory – Blood Lead Test Requisition
Form Instructions
Carefully read the following instructions. Using black or blue ink, complete the form in a clear and legible manner in the space
provided. If additional space or information is necessary, submit additional pages with this form. The electronic form is a fillable
document for typed entries.
Billing information may also be attached as a separate form; check box in Billing section “See Attached Sheet”.
Submitter Section:
1. You must enter Name, Address and Telephone Number of the Practice or District Office and the Referring Physician.
2. Enter the Contact person or Lead designee and Phone for the individual(s) responsible for receiving elevated results.
3. Enter the Primary Care practice if the Submitter is NOT the Primary Care Practice.
Patient Information Section:
1. The following fields must be entered: Last Name, First Name, and Date of Birth. This information must exactly match
the specimen label.
2. Select Gender, Race and Ethnicity
3. Enter Street Address, City, State and Zip Code.
4. Enter Name of Parent/Guardian and phone number if patient is a minor.
Specimen Information Section:
1. You must select the applicable source for the specimen.
2. Enter the Date of Collection.
3. Enter the appropriate ICD-10 code.
Laboratory Test Requested Section:
1. Select the test requested as Blood Lead.
Billing Information Section:
1. Provide insurance information or check “No Insurance”.
2. Insurance information may be included on an attached sheet.
Shipping Guidelines:
Microvette tubes should have the smaller collection tube inside the protective outer tube to protect the small purple cap.
This helps minimize sample loss and prevents contamination.
Specimens must be inside a small biohazard labeled recloseable bag in order to follow Universal Precautions.
Specimens can be shipped through the mail using VDHL mailing tubes, hand-delivered through a hospital courier or
dropped off at the VDH laboratory.
Microvettes, venous tubes, biohazard labeled recloseable bags, instruction sheets, postage paid mailing tubes and requisition
forms can all be ordered from the laboratory, free of charge, by calling Kit Preparation at (802) 338-4736 or use the order form.
The order form can be mailed back to the Laboratory or faxed to (802) 338-4706.
www.healthvermont.gov/lab/forms
All forms are available at the website
Under Forms and Ordering, the following forms are located:
✓ Blood Lead Test Requisition Form
✓ Blood Lead Specimen Collection Instructions
✓ Blood Lead Supplies Order Form
All fields are required to be filled out for VT/NH legal requirements for Reporting Blood Lead, CLIA
certification requirements and VDH billing information.
Inorg/Tox 200 Rev 1 (02/2019)
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