Home
Forms Library
Newborn Screening Release Request Form - Pennsylvania

Newborn Screening Release Request Form - Pennsylvania 2025

Newborn Screening Release Request Form - Pennsylvania Preview on Page 1

See details

4.5 out of 5

36 votes

The document is a Request for Specimen Release Form from the Pennsylvania Division of Newborn Screening and Genetics, detailing the process for releasing dried blood spot specimens held for one year. It outlines the necessary information required for the release, including details about the infant and parent/guardian, and provides contact information for submission.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Newborn Screening Release Request Form - Pennsylvania with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Newborn Screening Release Request Form in the editor.
Begin by entering the Birth Facility name in the designated field. This information is crucial for identifying where the infant was born.
Next, fill in the Infant’s Date of Birth accurately. This helps ensure that the request is processed for the correct child.
Provide the Infant’s Name at Discharge as it appears on official documents. This ensures proper identification of the specimen.
Indicate the Infant’s Sex in the specified section to complete demographic information.
Enter the Mother’s First and Last Name along with her Date of Birth to verify parental consent.
If known, include the Filter Paper Number, which can assist in locating specific specimens.
In the signature section, sign and date to authorize release of the specimen to your chosen health care provider or guardian.

Start using our platform today for free to easily complete your Newborn Screening Release Request Form!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the grounds for refusal for newborn screening?

Refusal to be Tested - A parent or legal guardian may refuse testing on the grounds of religious beliefs, but shall acknowledge in writing their understanding that refusal for testing places their newborn at risk for mental retardation or death of undiagnosed heritable conditions.

Are parents allowed to refuse newborn screening?

Is Newborn Screening Mandatory? In California, newborn screening is mandatory for all infants born in the state. This mandate protects childrens health by ensuring that they receive necessary screening regardless of their familys financial situation or educational background.

What is the newborn screening program in PA?

Program Overview: Newborn screening in Pennsylvania is completed to ensure every newborn is tested for metabolic, endocrine, hemoglobin, other diseases that can be identified through dried blood spot testing, heart disease, and hearing loss.

How do I opt out of newborn screening?

Opt-OutA parents right, in some states, to refuse newborn screening for their child: A parent or guardian of the newborn child may only decline newborn screening based on the objection that it conflicts with their religious beliefs or practices. They must then sign a test refusal form.

What is the expanded newborn screening program?

Expanded Newborn Screening Test It is a blood test done in newborn babies to screen for certain rare diseases and disorders which may have serious consequences if not detected and treated promptly. This test is also called extended new born screening test.

Under what condition can parents in Ohio refuse newborn screening?

Newborn screening saves lives and improves the health of babies and it is required by Ohio law for all babies born in Ohio. In some circumstances, parents can refuse newborn screening. Parents may refuse any type of newborn screening if it conflicts with their religious beliefs.

Can parents refuse newborn screening in California?

The goal of the program is to identify babies with these disorders early, so that treatment can be started right away. A parent or guardian of the newborn child may only decline newborn screening based on the objection that it conflicts with his or her religious beliefs or practices.

Is newborn screening optional?

Because NBS can be the only way to tell if a newborn has certain conditions, it is mandated (required) by state law in the United States (U.S.).

Newborn Screening Release Request Form - Pennsylvania 2025

Here's how it works