Newborn Screening Request Form (General) 2024

NEWBORN SCREENING (NBS) REQUEST FORM FOR INDIVIDUALS BORN IN VERMONT

IF THE INDIVIDUAL WAS NOT BORN IN VERMONT, PLEASE CONTACT THE NEWBORN SCREENING PROGRAM FOR THE STATE IN WHICH THE INDIVIDUAL WAS BORN.
Newborn screening provides information about a newborn’s risk of having a congenital or inherited conditon. Newborn screening does not provide diagnostic testing, and newborn screening results are not confirmation of a congenital or inherited condition. If there are clinical concerns for a screened condition, or known family history, we recommend the individual work with their provider to obtain a diagnostic test and appropriate counseling regarding the results. By requesting these results, the individual below acknowledges the risk in relying on newborn screening results as a means of verifying their (or their child’s) health status. If results are requested by email, the requester understands that the State of Vermont cannot guarantee the security of email transmissions of Protected Health Information (PHI).
Section 1.
Patient name:

First NameLast Name
Birth order (if a twin/multiple birth):
Parent/guardian full name (or birth parent’s name if different than legal parent/guardian):

First NameLast Name
Date of Birth:

MonthDayYear
Date
Hospital of Birth:
Name of birth hospital
Please fax screening report to:
Please send report to fax number:
Please enter a valid fax number.Format: (000) 000-0000.
Phone Number for follow up questions:
Please enter a valid phone number.Format: (000) 000-0000.
STOP HERE IF YOU ARE REQUESTING YOUR OWN OR YOUR CHILD’S NBS REPORT.
Health Care Providers: By this request, you certify that you are the current health care provider for the patient below.
Practice information:

Practice NameAttention
STOP HERE IF YOU ARE A PROVIDER REQUESTING A PATIENT’S NBS REPORT
Forms that are missing information may result in a delay. Rev 10/23/2024

Sections II-VI must be completed if report is to be sent to a party other than the individual or a health care provider.

Individuals who want the Vermont Newborn Screening Program to share information about them (or their minor child) with another person or organization must fill out all the sections below. If any sections are left blank, the permission will not be valid, and we will not be able to share information with the person(s) ororganization(s) listed.
SECTION II
I,
Name of parent/guardian
, give my permission to The Vermont Newborn Screening Program of the Vermont Department of Health, 280 State Dr., Waterbury, VT. 05671-8360, Phone: 802-951-5180 and 802-951-1218, to share my newborn screening results, or the newborn screening results of my child (if under 18) with the person(s) or organization(s) that I list in Section III below.
SECTION III - Who may receive my information.

The Vermont Newborn Screening Program may share my newborn screening results (or my child's screening results if under 18) with the following person(s) or organization(s). If more than one, list information for all recipients:
Person:

First NameLast Name
Organization:
Name of organization
Address:
Please enter a valid mailing address
Fax Number:
Please enter a valid fax number.Format: (000) 000-0000.
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
I understand that the person(s) or organization(s) listed in this section may not be covered by federal or state laws, and that they may be able to further share the information that is given them.
SECTION IV - Signature Please sign and date this form and print your name.
Individual's signature:
Individual's name:

First NameLast Name
Date:

MonthDayYear
Date
If this form is being filled out by someone who has the legal authority to act for the individual (such as the parent of a minor child, a court appointed guardian or executor, or health care agent), please print the name of the person filling out this form.

First NameLast Name
Signature of the person filling out this form:
Relationship to the individual:
Please provide any documents setting forth the legal authority, i.e. copy of an official birth certificate, court order, etc.

Attachment
Cancelof
Forms that are missing information may result in a delay. Rev 10/23/2024

SECTION V - Reason for sharing this information.
Explain
SECTION VI - How long this authorization lasts.
This information to share my information will expire (indicate date).

MonthDayYear
Date
If I do not list a date, this authorization will expire one year from the date it is signed. I understand that I can change my mine and withdraw this authorization at any time. To do this, I need to submit my withdrawal in wirtting to:

The Vermont Newborn Screening Program

Vermont Department of Health

280 State Dr.

Waterbury, VT 05671-8360

Phone: 802-951-5180

Fax: 802-951-1218.

If my information has already been lawfully shared by the Vermont Newborn Screening Program, I understand that I can only withdraw my authorization for any future disclosures.
Forms that are missing information may result in a delay. Rev 10/23/2024
Should be Empty:

NEWBORN SCREENING (NBS) REQUEST FORM FOR INDIVIDUALS BORN IN VERMONT

Sections II-VI must be completed if report is to be sent to a party other than the individual or a health care provider.