29 Dec 2011 ... DSHS EF05-13790 ... ask that the newborn hearing screening NOT ... for disability or injury to my baby that might have been found by hearing.
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How to fill out the Newborn Hearing Screening Refusal Form (English) - Dshs State Tx online
Filling out the Newborn Hearing Screening Refusal Form is an important process for parents and legal guardians who choose to decline the hearing screening for their newborn. This guide will provide clear and supportive instructions for completing the form online.
Follow the steps to complete the refusal form accurately and efficiently.
- Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
- In the first section, enter the name of the parent or legal guardian in the space provided. Clearly print the name to ensure accuracy.
- Next, fill in the baby’s name in the designated field. This identifies the child for whom the hearing screening is being declined.
- Fill in the name of the birthing facility in the corresponding line. This is the healthcare provider that typically conducts the hearing screening.
- After completing the identifying information, review the release statement. This indicates that you are releasing the healthcare provider from fault regarding any disabilities or injuries that might have been identified through the screening.
- Make sure to read the provided information regarding the newborn hearing screening thoroughly. This ensures that you understand the implications of your decision.
- Print the name of the parent or legal guardian again in the specified area to confirm responsibility.
- Provide your signature in the designated space. This signature serves as confirmation of your decision not to perform the hearing screening.
- Enter the date of signing the form, which is important for the record.
- Optionally, if there is a witness present, they may sign and date the form as well.
- Lastly, save your changes to the document. You can then download, print, or share the form as needed to maintain the records.
Take the next step and complete the Newborn Hearing Screening Refusal Form online today.
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Can parents opt out of newborn screening?
All states require screening to be performed on newborns, but most will allow parents to refuse for religious purposes. Any decision to decline or refuse testing should first be discussed with a health professional, since newborn screening is designed to protect the health of the baby.
What does the newborn screening test for in Texas?
The blood spots are screened for disorders that can affect a baby's amino acids, endocrine system, fatty acid oxidation, hemoglobin, organic acids, and other disorders. Point-of-service tests screen a newborn's hearing and for critical congenital heart disease (CCHD) before going home from the birthing facility.
What newborn screening is required by the state of Texas?
Newborn Screening for Critical Congenital Heart Disease in Texas. Reporting babies diagnosed with Critical Congenital Heart Disease (CCHD) is mandatory in Texas since September 2014.
Is newborn screening mandatory in Texas?
Newborn Screening is required by law for any baby born in Texas (Health and Safety Code, Chapter 33) and identifies babies that may have a specific disorder or medical condition.
What does Texas newborn screening test for?
The blood spots are screened for disorders that can affect a baby's amino acids, endocrine system, fatty acid oxidation, hemoglobin, organic acids, and other disorders. Point-of-service tests screen a newborn's hearing and for critical congenital heart disease (CCHD) before going home from the birthing facility.
Can you refuse newborn screening?
You must sign a test refusal form. The form states that not having the test done can result in serious illness or permanent damage to your child and that you accept responsibility should this occur.
What are newborns routinely tested for?
phenylketonuria (PKU) methylmalonic acidemia. maple syrup urine disease (MSUD) tyrosinemia. citrullinema. medium chain acyl CoA dehydrogenase (MCAD) deficiency.
What screenings are done on newborns?
Phenylketonuria (PKU). PKU is an inherited disease in which the body cannot metabolize a protein called phenylalanine. ... Congenital hypothyroidism. ... Galactosemia. ... Sickle cell disease. ... Maple syrup urine disease. ... Homocystinuria. ... Biotinidase deficiency. ... Congenital adrenal hyperplasia.
Can parents refuse newborn screening?
All states require screening to be performed on newborns, but most will allow parents to refuse for religious purposes. Any decision to decline or refuse testing should first be discussed with a health professional, since newborn screening is designed to protect the health of the baby.
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