CONFIDENTIALITY NOTICE: The information contained in the message and accompanying documents are legally privileged and confidential, intended
only for the use of the individual or entity named herein. If you have received this in error, please notify KHEL immediately by calling (785) 296-1620.
Rev. 11/19
CHANGE REQUEST AUTHORIZATION
This form is also used to request required information missing from a specimen submission form.
Facility Name
Facility Contact Person
Facility Phone Number
Facility Fax Number
KDHE Submission Form #
Date/Time
Patient Name
Date of Birth
MRN/HSN
Mother’s Name
Federal laboratory regulations require proper identification and complete demographic information on all specimens.
PLEASE COMPLETE OR VERIFY ONLY THE SELECTED MISSING INFORMATION:
Date of Birth Date of Collection
Physician Name
Specimen Source
Test(s) Requested
Diagnosis Code
Birth Weight Other
Patient Name
Last
Name First Name
Incorrect/Incomplete Information Correct Information
Add a Test (one patient per fax) (specify test)
I request the above mentioned report to be re-issued and/or I authorize the demographic correction/change/test addition
and agree to assume responsibility. This information may be received verbally, however this document must be signed
and faxed to the Kansas Health & Environmental Laboratories (KHEL) before final changes are made and final or
amended reports issued.
________________________________ ________________________________
Printed Name (REQUIRED) Signature (REQUIRED) Date
Securely email or fax completed form and/or supporting documentation to:
Virology/Serology Health Chemistry Microbiology Customer Service
(785) 559-5208 (785) 559-5209 (785) 559-5210 (785) 559-5205
KDHE.ViroSeroLab@ks.gov KDHE.HealthChemLab@ks.gov KDHE.MicroLab@ks.gov KDHE.LabCustomerService@ks.gov
click to sign
signature
click to edit
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