Get Student Athlete Request For Newborn Screening Hemoglobin Results - Cdph Ca

This guide provides clear instructions on how to effectively complete the Student Athlete Request For Newborn Screening Hemoglobin Results form online. By following these steps, users can ensure their requests are processed efficiently and accurately.

Follow the steps to complete your request form online.

1. Press the ‘Get Form’ button to access the Student Athlete Request For Newborn Screening Hemoglobin Results form. This will open the document in your preferred editing tool.
2. Fill in the student’s information, including their date of birth, first name, last name, and last name at birth (if applicable). Make sure to answer all required fields, marked by an underline. If you do not know the answer to a required question, enter 'UNK'.
3. Indicate whether the student was part of a multiple birth (e.g., twin or triplet). If so, specify their birth order using letters or numbers (A, B, C, or 1, 2, 3, etc.). Also provide the California city where the hospital is located and the hospital's name.
4. Complete the birth mother's information by providing her first name, last name, maiden name, and any other names she may have used. Accurate information is crucial for locating test results.
5. In the 'Release records to' section, select the school to which records should be sent from the dropdown menu. If the school is not listed, enter the school's name manually. Include the attention line for the person or department that should receive the results.
6. Provide your email address if you would like a copy of the results emailed to you. If a physical copy is desired as well, check the appropriate box and provide a mailing address.
7. Specify the expiration date for the authorization to release records. It is set to default as one year from the current date. If needed, change this date accordingly.
8. Sign the form. The student must sign if they are 18 or older; otherwise, a parent or legal guardian must sign. Print the completed form and sign it in ink, as electronic signatures are not accepted.
9. Once completed, return the signed form to the school athletic personnel, who will either mail or fax it to the Genetic Disease Screening Program at the specified address.
10. After submitting the form, ensure to download and save a copy for your records. You may also choose to print the form for a hard copy.

Ensure your request is processed by completing your documents online today.