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OREGON
REQUEST FOR NEWBORN SCREENING KITS
The Newborn Screening Program is completely fee supported.
Fees are collected at the time kits are ordered (kits are prepaid); there is no additional fee for performing the newborn screening tests. To order newborn screening kits, print these pages, complete the form, attach your check, and mail to the address indicated.
According to Oregon Administrative Rule 333-24-240(4)(b),
prepayment of Newborn Screening kits will be required.
1. Completely fill out this form to ensure you will get the
correct kits.
2. To your order, ATTACH A CHECK OR MONEY ORDER, payable to:
DEPARTMENT OF HUMAN SERVICES
FISCAL SERVICES
PO BOX 14260
PORTLAND, OR 97293-0260
ATT:
FACILITY NAME__________________________________SUBMITTER CODE NO._________
STREET ADDRESS________________________________________________________________
(NOT PO BOX)
CITY________________________ STATE__________________ ZIP__________________
TELEPHONE NO._______________________PO#_________ORDERED BY____________
EFFECTIVE OCTOBER 14, 2002: (PLEASE ALLOW 2-3 WEEKS FOR DELIVERY)
Number of Double Kits ____ x $54.00 = $_______
Number of Single Kits ____ x $27.00 = $_______
Place Bar Code here:
Verified______ |
Items listed below may be obtained at any time-no charge:
(please specify amount needed)
Spanish Information pamphlet_______
English Information pamphlet_______
Manila Envelopes________
Striped Envelopes________
Other________
QUESTIONS? Please call Newborn Screening at: (503) 229-5466.
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REVENUE CODE 1252
FUND CODE 48932 21000
TOTAL $_________ (AMOUNT ENCLOSED)
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PHL USE ONLY:
KIT NUMBERS________________________
___________________________________
___________________________________
___________________________________
DATE SENT__________________________
BY___________REVIEWED BY___________
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In compliance with the Americans with Disabilities Act (ADA), if you need this information in an alternate format please call: Oregon State Public Health Laboratories at: (503) 229-5882.
Free software to view, navigate, and print Portable Document Files (PDFs) can be downloaded from Adobe (go get Acrobat Reader)
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