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State Forms

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The following forms are intended for use by both families and providers, unless specified otherwise.

  • State Form 54102: Religious Waiver for Newborn Screening (en español)
    • For Provider Use Only: This form must be filled out and signed by the parent and hospital staff/midwife in every instance of a refusal of newborn screening. Every religious refusal must be entered as a Monthly Summary Report (MSR) exception within INSTEP by every birthing facility/midwife. Scan the completed Religious Waiver and upload it into the MSR exception in INSTEP. If the birthing facility/midwife is unable to electronically upload the Religious Waiver, they may fax it to the NBS Care Coordinator at 317-234-2995.
  • State Form 55649: Genomics and Newborn Screening Access Request
    • This form should be filled out by parents or provider to request newborn screening results or dried blood spot specimens. Parents are required to submit identification along with this request form.
  • State Form 55650: Request for Destruction of Dried Blood Spot
    • This form should be filled out by parents who wish to have their child's dried blood spot specimen destroyed. If parents consent to storage, the specimen will be destroyed 3 years after time of collection. This form is intended to be used by parents within this 3-year timeframe who previously consented to storage of the dried blood spot, but change their mind and wish to have the specimen destroyed within the 3 years. Please note, all specimens will be kept for a minimum of 6 months after time of collection to allow for additional screening, if necessary.
  • State Form 55651: Request for Storage of Dried Blood Spot
    • This form should be filled out by parents who wish to have their child's dried blood spot specimen stored for 3 years. If the parents previously did not consent for storage of the dried blood spot, this form must be completed within 6 months after the heel stick was performed.

Page last revised 06/30//2021 by JWeaver