Childhood blood lead level report form - Texas Department of State ... - dshs state tx 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Provider Name and contact details, including Fax Number and Phone Number, ensuring all information is accurate for effective communication.
3. Fill in the Child Information section. Enter the child's Last Name, First Name, Middle Initial, Date of Birth, Gender, Age in Months, Medicaid/CHIP ID#, and Current Address. Be sure to check the appropriate boxes for Ethnicity and Race.
4. In the Blood Lead Level Information section, input the Blood Lead Test Level in micrograms per deciliter (mcg/dL) and select the Type of Blood Sample taken. If applicable, place the label from the LeadCare System here.
5. Complete the Testing Laboratory details along with its phone number and Test Date.
6. Finally, provide Attending Physician Information including their Last Name and First Name along with their Location (City).

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