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Laboratory use onlyGEORGIA PUBLIC HEALTH LABORATORY SUBMISSION FORM(Do Not Use for Newborn Screening Tests)Choose Lab to Perform TestPerformed at the Decatur Laboratory unless specified* FORMCHECKBOX Decatur FORMCHECKBOX Waycross Complete a separate form for each test requestedHEALTH CARE PROVIDER INFORMATION PATIENT INFORMATIONSubmitter CodePatient ID NumberPATIENT NAME (Last) FirstMISuffix FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT ????? FORMTEXT ? ???? FORMTEXT ?? ?? FORMTEXT FORMTEXT Submitter Name County of ResidenceDOB FORMTEXT ????? FORMTEXT ?? ?? ? FORMTEXT ___/ FORMTEXT ___/ FORMTEXT ______Street AddressHome Phone:Work Phone:Cell Phone: FORMTEXT ????? FORMTEXT ? ? ? FORMTEXT ? ???? FORMTEXT ? ????CityStateZipAddressCity,StateZip FORMTEXT ????? FORMTEXT FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? ? FORMTEXT FORMTEXT ?????Phone NumberParent / Guardian (if applicable) Relationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? ?Fax NumberRACE ETHNICITYSex FORMTEXT ????? FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black/African-American FORMCHECKBOX Native Hawaiian/Pacific Islander FORMCHECKBOX White/ Caucasian FORMCHECKBOX Multi Racial FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Non-Hispanic or Latino FORMCHECKBOX Male FORMCHECKBOX FemaleContact NamePregnant? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ????? FORMCHECKBOX SELF PAY (SUBMITTER WILL BE INVOICED) FORMCHECKBOX APPROVAL CODE: FORMTEXT ______- FORMTEXT ?????- FORMTEXT ?????- FORMTEXT __________(Submitter will be billed if a valid code is not provided)INSURANCE INFORMATION – COPY OF PATIENT’S INSURANCE ELIGIBILITY DOCUMENT MUST BE SUBMITTED WITH THIS FORMFOR FUTURE USEACCEPTED INSURANCE FORMCHECKBOX Amerigroup FORMCHECKBOX Peach State FORMCHECKBOX Wellcare FORMCHECKBOX Medicaid/ PeachcareID Number Plan NameGroup NumberPolicy Holder’s Name (Last, First, M) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ? ????, FORMTEXT ?? ??? FORMTEXT Policy Holder’s DOBPolicy Holder’s Mailing AddressPatient’s Relationship to Policy Holder FORMTEXT ___/ FORMTEXT ___/ FORMTEXT ______ FORMTEXT ????? FORMTEXT ?????Insurance Phone #Insurance Mailing AddressCoverage Effective Date FORMTEXT ????? FORMTEXT ????? FORMTEXT ___/ FORMTEXT ___/ FORMTEXT ______ICD 9 Diagnosis CodesRequired for insurance purposes only. Sequence Code 1 Sequence Code 2 Sequence Code 3 FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ?SPECIMEN INFORMATION *All tests are performed at the Decatur Laboratory unless specified.* TEST REQUESTEDSpecimen Type: FORMCHECKBOX Arthropod Type: FORMTEXT __________________ FORMCHECKBOX Abscess Source: FORMTEXT _________________ FORMCHECKBOX Body Fluid Source: FORMTEXT ________________ FORMCHECKBOX Bronchial Wash FORMCHECKBOX Bronchoalveolar Lavage FORMCHECKBOX Buccal Swab FORMCHECKBOX Bronchial Wash FORMCHECKBOX Broth FORMCHECKBOX Cerebral Spinal Fluid FORMCHECKBOX Dried Blood Spot FORMCHECKBOX Endocervical Swab FORMCHECKBOX Isolated OrganismSource: FORMTEXT _________________ FORMCHECKBOX Lesion/General Swab FORMCHECKBOX Lesion/Genital Swab FORMCHECKBOX Lymph Node Aspirate FORMCHECKBOX Nasal Wash FORMCHECKBOX Nasal Aspirate FORMCHECKBOX Nasal Swab FORMCHECKBOX Nasopharyngeal Aspirate FORMCHECKBOX Nasopharyngeal Swab FORMCHECKBOX Pinworm/Adhesive Slide FORMCHECKBOX Plasma FORMCHECKBOX Rectal Swab FORMCHECKBOX Scab FORMCHECKBOX Serum FORMCHECKBOX Sputum FORMCHECKBOX Rectal Swab FORMCHECKBOX Stool/Feces (Fresh) FORMCHECKBOX Stool/Feces (Preserved) FORMCHECKBOX Throat/Pharynx FORMCHECKBOX Tissue Source: FORMTEXT _________________ FORMCHECKBOX Urethral Swab FORMCHECKBOX Urine FORMCHECKBOX Vaginal Swab FORMCHECKBOX Vesicle Fluid/Swab FORMCHECKBOX Whole Blood FORMCHECKBOX Other: ______________ Date of Collection FORMTEXT ____/ FORMTEXT ____/ FORMTEXT ________ Time of Collection FORMTEXT _____: FORMTEXT _____ FORMCHECKBOX AM FORMCHECKBOX PM Shipped: FORMCHECKBOX Frozen FORMCHECKBOX Refrigerated FORMCHECKBOX Room TemperatureOutbreak related FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name of outbreak: FORMTEXT _______________________Travel FORMCHECKBOX Yes FORMCHECKBOX No Where? FORMTEXT _______________________ Symptoms FORMTEXT __________________________________________________________________ Date of onset FORMTEXT ____/ FORMTEXT ____/ FORMTEXT ________BLOOD LEAD(Waycross Only) FORMCHECKBOX W4050 Waycross COLLECTION METHOD FORMCHECKBOX Capillary FORMCHECKBOX Venous MOLECULAR BIOLOGY(Decatur only)Consultation with district epidemiologist required. FORMCHECKBOX BT Agent Rule Out (RT-PCR) FORMCHECKBOX BTC01005 Bacillus anthracis FORMCHECKBOX BTC02005 Brucella spp. FORMCHECKBOX BTC03005 Burkholderia mallei/pseudomallei FORMCHECKBOX BTC04005 Francisella tularensis FORMCHECKBOX BTC06005 Yersinia pestis FORMCHECKBOX BT99000 BT send out CDC FORMCHECKBOX 414000 Bordetella pertussis (RT-PCR) FORMCHECKBOX 40000 Influenza Panel with Respiratory Culture/IFA FORMCHECKBOX 400050 Influenza Panel (rRT-PCR) FORMCHECKBOX 413000 Mumps (RT-PCR) FORMCHECKBOX 416000 Measles (RT-PCR) FORMCHECKBOX 1305 Norovirus (rRT-PCR) FORMCHECKBOX BTC05000 Rash Illness Panel (RT-PCR) FORMCHECKBOX 421000 VZV (RT-PCR) FORMCHECKBOX 49100 Miscellaneous Molecular FORMCHECKBOX 499100 Refer to CDC FORMTEXT ________________A correlating list of tests and prices is located at Page 1of 2 - Form 3583 (Revised 3/27/2014)PATIENT NAME Last: FORMTEXT ????? First: FORMTEXT ????? MI. FORMTEXT For Laboratory Use Only BACTERIOLOGY IMMUNOLOGY FORMCHECKBOX Enteric Isolates FORMCHECKBOX 1100 Campylobacter FORMCHECKBOX 1070 STEC FORMCHECKBOX 1110 Salmonella FORMCHECKBOX 1080 Shigella FORMCHECKBOX 1160 Yersinia FORMCHECKBOX 1120 Stool Culture - Preserved (Para-Pak C&S, Room Temp) FORMCHECKBOX Routine (Salmonella, Shigella, Campylobacter, Aeromonas, STEC, and Yersinia) FORMCHECKBOX S. aureus 1 FORMCHECKBOX 1140 Stool Culture- Fresh (Refrigerated) FORMCHECKBOX B. cereus 1 FORMCHECKBOX C. perfringens 1 FORMCHECKBOX 1130 Special Bacteriology FORMCHECKBOX Neisseria meningitidis FORMCHECKBOX Haemophilus influenzae FORMCHECKBOX Listeria monocytogenes FORMCHECKBOX Vibrio spp. FORMCHECKBOX Other- Suspected agent FORMTEXT ????__________________________________________________________? FORMCHECKBOX 1040 Pertussis Direct Fluorescent Antibody (DFA) FORMCHECKBOX 1050 Pertussis Culture FORMCHECKBOX 1030 Group A Streptococcus FORMCHECKBOX 1010 Gonorrhea Culture FORMCHECKBOX Nucleic Acid Amplification Test (Chlamydia/Gonorrhea) FORMCHECKBOX 1060 Decatur FORMCHECKBOX W1000 Waycross FORMCHECKBOX 1135 Forward to CDC1 (Please specify) FORMTEXT __________________________ FORMCHECKBOX C. botulinum 1,2 FORMTEXT ________________________________________________________________1 Special arrangement required CALL 404-327-7997 2 Epidemiology approval required CALL 404-657-2588 FORMCHECKBOX 1180 ENVIRONMENTAL / FOOD (Epidemiology Use Only) FORMCHECKBOX B. cereus FORMCHECKBOX Campylobacter FORMCHECKBOX C. perfringens FORMCHECKBOX Listeria FORMCHECKBOX STEC / SLT FORMCHECKBOX Salmonella FORMCHECKBOX Shigella FORMCHECKBOX S. aureusRoutine Syphilis FORMCHECKBOX Routine RPR (Choose nearest location) FORMCHECKBOX 1610 Decatur FORMCHECKBOX W2000 Waycross FORMCHECKBOX 1630 VDRL (spinal fluid) FORMCHECKBOX 1640 TPPASpecial RPR testing request FORMCHECKBOX 1615 Quantitative (Titer) and Confirmatory even if screening test (RPR) is negative FORMCHECKBOX No Confirmatory Test needed even if screening test (RPR) is positive Arbovirus/WNV panel FORMCHECKBOX 1595 Arbo IgG panel FORMCHECKBOX 1600 Arbo IgM panel FORMCHECKBOX 1580 WNV lgG FORMCHECKBOX 1585 WNV lgM FORMCHECKBOX 1590 WNV lgM (CSF)Hepatitis Testing FORMCHECKBOX 1411 Hep B (Prenatal) FORMCHECKBOX 1410 Hep B (Routine Screen) FORMCHECKBOX 1400 Anti-HAV Total Antibody FORMCHECKBOX 1405 Anti-HAV-IgM FORMCHECKBOX 1480 Anti-HCV (Ab) with reflex to HCV RNA FORMCHECKBOX 1490 HCV Viral LoadMiscellaneous Serology FORMCHECKBOX 1530 Toxoplasmosis IgG FORMCHECKBOX 1535 Toxoplasmosis IgM FORMCHECKBOX 1510 Rubella IgG FORMCHECKBOX 1515 Rubella IgM FORMCHECKBOX 1545 CMV IgG FORMCHECKBOX 1550 CMV IgM FORMCHECKBOX 1560 HSV1 FORMCHECKBOX 1565 HSV2 FORMCHECKBOX 1520 Rubeola IgG FORMCHECKBOX 1525 Rubeola IgM FORMCHECKBOX 1555 Mumps FORMCHECKBOX 1540 Varicella Zoster FORMCHECKBOX 14001 Torch Panel (CMV, HSV1, HSV2, Rubella, and Toxoplasmosis) FORMCHECKBOX 1570 Forward to CDC FORMTEXT ??__________________ ______________? MYCOBACTERIOLOGY VIROLOGY CHEMICAL THREATKnown TB Patient? FORMCHECKBOX Yes, current FORMCHECKBOX Yes, former FORMCHECKBOX NoClinical Specimens FORMCHECKBOX 30100 Microscopic exam for AFB only FORMCHECKBOX 30000 Smear, culture & susceptibility testing (Susceptibility Performed on MTB only) FORMCHECKBOX 30800 Nucleic Acid Amplification Testing (NAAT). This test is intended for use only with specimens from newly infected patients showing signs and symptoms of active pulmonary tuberculosis. AFB Isolates FORMCHECKBOX 34000 Identification FORMCHECKBOX 33950 Susceptibility testing (MTB only) FORMCHECKBOX 30750 Genotyping onlyHIV CTS# FORMTEXT _________________________ FORMCHECKBOX 13500 HIV Ag/Ab Combo FORMCHECKBOX 1360 HIV-1 Ab WB (dried blood spot only) FORMCHECKBOX 1340 HIV-1 Viral LoadVIRAL CULTURE FORMCHECKBOX 62050 CMV Culture/IFA FORMCHECKBOX 62040 Measles Culture/IFA FORMCHECKBOX 60000 Mumps Culture/IFA FORMCHECKBOX 1385 Enterovirus Culture / IFA FORMCHECKBOX 1330 Herpes Culture / ELVIS FORMCHECKBOX 62000 VZV Culture / IFA FORMCHECKBOX 6100 Respiratory Culture / IFA FORMCHECKBOX 1375 Influenza Culture / IFA FORMCHECKBOX Other: FORMTEXT _____________/IFA FORMCHECKBOX 60040 Viral Culture / Identification (Please specify): FORMTEXT ________________ FORMCHECKBOX Gastrointestinal Outbreak Investigation FORMCHECKBOX 60030 Rotavirus EIA Miscellaneous Virology FORMCHECKBOX 60160 Virology CDC Sendout (Please specify: FORMTEXT ___________________ (Decatur only)Consultation with GPHL Emergency Response Coordinator required. 24/7 contact number 404-655-3695 866-782-4584 FORMCHECKBOX CT041100 Rapid Toxic Screen (RTS) (Performed at the CDC) FORMCHECKBOX CT021500 Cadmium, mercury and lead (blood) FORMCHECKBOX CT021700 Toxic Elements Screen (TES) (As, Ba, Be, Cd, Pb, Tl, U) (urine) FORMCHECKBOX CT021600 Mercury (urine) FORMCHECKBOX CT011100 Cyanide (blood) FORMCHECKBOX CT011200 Volatile Organic Compounds (VOC) (blood) FORMCHECKBOX CT011300 Tetramine (urine) FORMCHECKBOX CT031100 Organophosphate Nerve Agent metabolites (OPNA) (urine) FORMCHECKBOX CT031200 Metabolic Toxins Panel (MTP) (urine) FORMCHECKBOX CT031300 Abrine and Ricinine (ABRC) (urine) FORMCHECKBOX Hold for testing Illness related to chemical exposure FORMCHECKBOX Yes FORMCHECKBOX NoName/ID number of event : FORMTEXT __________________ PARASITOLOGY (Choose nearest location) FORMCHECKBOX Ova and Parasites Exam (Includes Formalin and PVA)Formalin Feces FORMCHECKBOX 2100 Decatur FORMCHECKBOX W5000 Waycross PVA Feces FORMCHECKBOX 2300 Decatur FORMCHECKBOX W5020 Waycross Pinworm slide FORMCHECKBOX 2200 Decatur FORMCHECKBOX W5030 Waycross FORMCHECKBOX 2150 PCR FORMCHECKBOX 2710 Tissue/tissue smear for parasites FORMCHECKBOX 2700 Whole blood/blood smear for parasites - Malaria FORMCHECKBOX 2710 Whole blood/blood smear for parasites - Filaria FORMCHECKBOX 2800 Worm identification FORMCHECKBOX 2800 Miscellaneous identification FORMTEXT ?___?___________________For epidemiology use only:Cryptosporidium (with O&P) FORMCHECKBOX 2100 Decatur FORMCHECKBOX W5000 Waycross Cyclospora (with O&P) FORMCHECKBOX 2100 Decatur FORMCHECKBOX W5000 Waycross All tests are performed at the Decatur Laboratory unless specified.A correlating list of test and prices is located at Page 2 of 2 – Form 3583 (Revised 6/28/13) ................
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