State of California - Health and Human Services Agency California Department of Public Health - Genetic Disease Screening Program
FIRST NAME LAST NAME
LAST NAME AT BIRTH
DATE OF BIRTH (MM/DD/YYYY)
CITY (AT TIME OF BIRTH)
DATE SIGNED (MM/DD/YYYY)
BEST PHONE NUMBER TO REACH YOU
BEST EMAIL ADDRESS TO REACH YOU
THE UNDERSIGNED HEREBY AUTHORIZES THE RELEASE OF NEWBORN SCREENING HEMOGLOBIN TEST RESULTS FROM THE RECORDS OF THE CALIFORNIA GENETIC DISEASE SCREENING
PROGRAM. MUST BE SIGNED BY STUDENT IF 18 OR OLDER. PARENT OR LEGAL GUARDIAN SHOULD SIGN ONLY IF STUDENT UNDER THE AGE OF 18.
STUDENT'S INFORMATION
GENETIC DISEASE SCREENING PROGRAM ● NEWBORN SCREENING BRANCH ● 850 MARINA BAY PARKWAY, F175 ● RICHMOND, CA 94804
Website: www.cdph.ca.gov/programs/nbs ● E-mail questions to: NCAANBSResults@cdph.ca.gov ● FAX: 510/412-1559
CDPH 4400 (ENG) (06/13)
WERE YOU PART OF A MULTIPLE BIRTH?
YES NO
(With area code)
HOSPITAL OF BIRTH
BIRTH MOTHER'S INFORMATION
MAIDEN NAME
FIRST NAME LAST NAME
OTHER NAMES USED
RELEASE RESULTS TO
SCHOOL ATTENTION (Person or Department)
SIGNATURE (STUDENT IF OVER 18, PARENT/GUARDIAN IF STUDENT NOT OVER 18) PRINTED NAME
YOU HAVE THE RIGHT TO RETAIN A COPY OF THIS CONSENT. YOU HAVE THE RIGHT TO REVOKE THIS CONSENT AT ANY TIME BY WRITING TO: CHIEF, GENETIC DISEASE SCREENING
PROGRAM AT 850 MARINA BAY PARKWAY, F175, RICHMOND, CA 94804. THE GENETIC DISEASE SCREENING PROGRAM IS NOT RESPONSIBLE FOR FURTHER DISCLOSURES OF THE
INFORMATION BY OTHER PARTIES THAT MAY RESULT FROM COMPLYING WITH THIS CONSENT.
SIGNATURE
I understand that any person who requests or obtains any record containing personal information from the California Department of Public
Health under false pretenses will be guilty of a misdemeanor and fined up to $5,000 or imprisoned up to one year or both.
(If different than your current last name)
AUTHORIZATION FOR THE RELEASE
OF YOUR RECORDS WILL EXPIRE ON:
(Choose from dropdown. If school not listed, provide name and give an email address below.)
GENDER
MALE FEMALE
IF YES, WHERE WERE YOU
IN THE BIRTH ORDER?
(in other words were you a twin, triplet or more?)
(Usually A, B, C or 1, 2, 3... etc.)
The Genetic Disease Screening Program (GDSP) is defined as a health care provider under HIPAA and is a covered entity. GDSP is therefore
required to distribute a Notice of Privacy Practice (NPP).
PRIVACY NOTIFICATION
NCAA STUDENT ATHLETE REQUEST FOR NEWBORN SCREENING HEMOGLOBIN RESULTS
To Meet the National Collegiate Athletic Association Sickle Cell Trait Proof of Testing Requirement
Required questions are underlined and must be completed. If you cannot answer a required question place NA in the field.
Submitting form on line will SUBSTANTIALLY speed up results! If completing by hand, type or print neatly in ink and be prepared to wait.
Students need not resubmit this form if they already submitted one in a previous year - NBS results do not change.
•
•
•
(A default 1 year from today is given. You may
type in a new date if completing online or cross
out and put in new date if completing by hand.)
CITY WHERE BIRTH HOSPITAL LOCATED
MOTHER'S DATE OF BIRTH
IF RESULTS ARE TO BE SENT TO A SCHOOL NOT LISTED
IN THE DROP DOWN MENU ABOVE, PLEASE PROVIDE AN
EMAIL ADDRESS WHERE RESULTS SHOULD BE SENT:
ADDRESS AT TIME OF
BIRTH IS NOT REQUIRED,
BUT IT IS VERY HELPFUL
FOR FINDING RESULTS
STREET ADDRESS (AT TIME OF BIRTH)
The collection and exchange of personal health information between covered providers for the purpose of treatment, payment, or health care
operations with GDSP and our agents in connection with the newborn and prenatal screening programs is permitted by HIPAA and required by
state law without special authorization or Business Associates Agreements.
OR
(In case we need to contact you with questions)
After the online submission of data, print a copy of form, sign in ink (If student over 18, student must sign. If student under 18, parent must
sign.). Mail or fax to the Genetic Disease Screening Program (address at bottom of this page). IMPORTANT - Results not released until a signed
form received!
•
leroy.heu@athletics.ucsb.edu
