California Newborn Screening Program
To order any of these forms, please call (510) 412-1542 or fill out this form and submit by email.
Newborn Screening Missing Result Form (NBS-MR):
Used by perinatal licensed health facilities when an NBS specimen was collected but no results have been received.
Hospital Report of Newborn Screening Specimen Not Obtained (NBS-NO):
Used by perinatal licensed health facilities to report infants discharged without an NBS test, including those transferred to another hospital before a specimen is collected.
Notification of Registration of Birth Which Occurred Outside of a Licensed Health Facility (NBS-OH):
Used by county birth registrars to report babies born outside of a licensed health facility.
Newborn Screening Test Refusal (NBS-TR): English or Spanish
Completed and signed by parent(s) who are refusing for religious reasons to have a newborn screening specimen collected on their child.
Consent for Disclosure and/or Release of Confidential Information from GDSP
Consent for Disclosure and/or Release of Dried Blood Specimen from GDSP
Request to Restrict Use and Disclosure of Personal Information by Parent, Guadian or Personal Representative click on CDPH 6241