Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. Begin by entering patient information, including their last name, first name, date of birth, and state of residence. Ensure accuracy in spelling and data entry.
3. Provide the patient's ethnicity and race by selecting the appropriate boxes from the options given.
4. Indicate whether the patient is insured and if so, confirm if the insurance will be billed.
5. Complete the provider information including the provider's name, code, contact details, and email address.
6. Select the specimen source from the provided list to specify the type of sample being submitted.
7. Fill out the section for additional information regarding any specific diseases suspected or tests required.
8. Review all entered information for accuracy and completeness before proceeding.
9. Once all fields are filled out, save your changes.
10. Finally, download, print, or share the completed form as necessary for submission.

Complete the form online to contribute to the public health response effectively.