New Jersey Department of Health
|New Jersey Department of Health |ORDER FORM FOR | |
|Newborn Screening (NBS) - Billing Unit |INITIAL NEWBORN SCREENING REQUEST |Distribution:|
|P. O. Box 361 |(IEM-1) FORMS |ORIGINAL-To |
|Trenton, NJ 08625-0361 | |be Returned |
| | |to Requester |
| | |COPY-NJDOH, |
| | |Laboratory |
| | |File |
| | |COPY-To be |
| | |Retained by |
| | |Requester |
|FORM TITLE |QUANTITY |COST PER FORM |TOTAL COST |FOR STATE USE ONLY | |
|Initial Newborn | |x $90.00 = |$ | | |
|Screening Request | | | | | |
| | |
|Name and Mailing Address of Requester | |Make Check/Money Order Payable to: | |
| | |“NEW JERSEY DEPARTMENT OF HEALTH” | |
| | | | |
| | | | |
| | |Check/Money Order Number and Date | |
| | | | |
| | | | |
| | |Ship Date | |
| | | | |
| | | | |
|IEM-15 | |
|OCT 14 | |
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