GEORGIA PUBLIC HEALTH

Laboratory use only

LABORATORY SUBMISSION FORM
(Not to be used for Newborn Screening Tests) 1
Complete a separate form for each test requested
Effective 7/1/2013 Please Do Not Submit this form prior to
Choose Lab to Perform Test
7/1/2013 Decatur Waycross

HEALTH CARE PROVIDER2INFORMATION 3 4

PATIENT INFORMATION
Submitter Code Patient ID Number PATIENT NAME (Last) First MI Suffix

Submitter Name County of Residence DOB

___/___/______
Street Address 5 Home Phone: Work Phone: Cell Phone:

City State Zip Address City, State Zip

Phone Number Parent / Guardian (if applicable) Relationship

Fax Number RACE ETHNICITY Sex

American Indian/Alaska Native Asian Hispanic or Latino Male
Black/African-American Non-Hispanic or Latino Female
Native Hawaiian/Pacific Islander
Contact Name 6 White/ Caucasian
Pregnant?
Yes No N/A
Multi Racial

SELF PAY (SUBMITTER WILL BE INVOICED) APPROVAL CODE: ______- - -__________ (Submitter will be billed if a valid code is not provided)

INSURANCE INFORMATION – COPY OF PATIENT’S INSURANCE ELIGIBILITY DOCUMENT MUST BE SUBMITTED WITH THIS FORM
ACCEPTED INSURANCE ID Number Plan Name Group Number Policy Holder’s Name (Last, First, M)
Amerigroup ,
Peach State Policy Holder’s DOB Policy Holder’s Mailing Address Patient’s Relationship to Policy Holder
Wellcare
___/___/______
Medicaid/
Peachcare Insurance Phone #
DO NOT USE
Insurance Mailing Address Coverage Effective Date
___/___/______
ICD 9 Diagnosis Codes Sequence Code 1 Sequence Code 2 Sequence Code 3
Required for insurance purposes only.
SPECIMEN INFORMATION *All tests are performed at the Decatur Laboratory unless specified.* TEST REQUESTED
Arthropod 7 Date of Collection BLOOD LEAD CHEMICAL THREAT
Abscess ____/____/________ (Waycross Only) (Decatur only)
Blood W4050 Waycross Consultation with GPHL Emergency Response
Body fluid Coordinator required.
8 Time of Collection
Bronchial Wash
CSF
_____:_____ AM PM
COLLECTION METHOD
Capillary Venus
DO NOT USE 24/7 contact number 404-655-3695
866-782-4584
Endocervical
SHIPPED MOLECULAR BIOLOGY CT041100 Rapid Toxic Screen (RTS)
9
Isolated Organism
Frozen (Decatur only) (Performed at the CDC)
Lesion/General Swab Consultation with district epidemiologist
Refrigerated CT021500 Cadmium, mercury and lead (blood)
Lesion/Genital Swab required. CT021700 Toxic Elements Screen (TES) (urine)
Nasopharyngeal Aspirate Room Temperature BT agent rule out (RT-PCR) (As, Ba, Be, Cd, Pb, Tl, U)
Nasopharyngeal Swab BTC01005 Bacillus anthracis CT021600 Mercury (urine)
Pinworm Outbreak related Yes BTC02005 Brucella spp. CT011100 Cyanide (blood)
Plasma No BTC03005 B. mallei/pseudomallei CT011200 Volatile Organic Compounds (VOC)
If yes, name of outbreak: BTC04005 Francisella tularencis (blood)
Rectal Swab
________________________ BTC06005 Yersinia pestis CT011300 Tetramine (urine)
Serum BT99000 BT send out CDC
(Acute/Convalescent) CT031100 Organophosphate Nerve Agent
414000 Bordetella pertussis (RT-PCR)
Sputum Travel Yes No metabolites (OPNA) (urine)
400050 Influenza panel (rRT-PCR) CT031200 Metabolic Toxins Panel (MTP) (urine)
Stool/Feces Where? 413000 Mumps (RT-PCR)
_______________________ 416000 Measles (RT-PCR) CT031300 Abrine and Ricinine (ABRC) (urine)
Throat/Pharynx Hold for testing
Tissue Symptoms 1305 Norovirus (rRT-PCR)
Urethra
10 ________________________ BTC05000 Rash Illness Panel (RT-PCR)
Illness related to chemical exposure
421000 VZV (RT-PCR)
Urine ________________________
499100 Refer to CDC Yes No
________________________
Other _________________ ____________ ___________ Name/ID number of event __________________
A correlating list of tests and prices is located at http://health.state.ga.us Page 1of 2 - Form 3583 (Revised 6/28/13)
PATIENT NAME For Laboratory Use Only
Last: First: MI.
BACTERIOLOGY IMMUNOLOGY
Enteric isolates Routine Syphilis
1100 Campylobacter Routine RPR (Choose nearest location)
1070 STEC 1610 Decatur W2000 Waycross
1110 Salmonella 1630 VDRL (spinal fluid)
1640 TPPA
1080 Shigella
1160 Yersinia
1120 Stool Culture - Preserved (Para-Pak C&S, Room Temp)
DO NOT USE
Special RPR testing request
1615 Quantitative (Titer) and Confirmatory even if screening test (RPR) is
Routine (Salmonella, Shigella, Campylobacter, Aeromonas, STEC, and Yersinia) negative
S. aureus 1 No Confirmatory Test needed even if screening test (RPR) is positive
1140 Stool Culture- Fresh (Refrigerated)
B. cereus 1 Arbovirus/WNV panel
C. perfringens 1 1595 Arbo IgG panel
1130 Special Bacteriology 1600 Arbo IgM panel
1580 WNV lgG
Neisseria meningitidis
1585 WNV lgM
Haemophilus influenzae 1590 WNV lgM (CSF)
Listeria monocytogenes
Vibrio sp. Hepatitis Testing
Other- Suspected agent 1411 Hep B (Prenatal)
__________________________________________________________ 1410 Hep B (Routine Screen)
1040 Pertussis Direct Fluorescent Antibody (DFA) 1400 Anti-HAV Total Antibody
1050 Pertussis Culture 1405 Anti-HAV-IgM
1030 Group A Streptococcus 1480 Anti-HCV
1490 HCV Viral Load
1010 Gonorrhea Culture
Nucleic Acid Amplification Test (Chlamydia/Gonorrhea) Miscellaneous Serology
1060 Decatur W1000 Waycross 1530 Toxoplasmosis IgG
1135 Forward to CDC1 (Please specify) __________________________ 1535 Toxoplasmosis IgM
C. botulinum 1,2 1510 Rubella IgG
________________________________________________________________ 1515 Rubella IgM
1 Special arrangement required CALL 404-327-7997 1545 CMV IgG
2 Epidemiology approval required CALL 404-657-2588 1550 CMV IgM
1560 HSV1
1565 HSV2
1180 ENVIRONMENTAL / FOOD (Epidemiology Use Only) 1520 Rubeola IgG
B. cereus 1525 Rubeola IgM
Campylobacter 1555 Mumps
C. perfringens 1540 Varicella Zoster
Listeria 14001 Torch Panel (CMV, HSV1, HSV2, Rubella, and Toxoplasmosis)
STEC / SLT
Salmonella 1570 Forward to CDC __________________ ______________
Shigella
S. aureus

MYCOBACTERIOLOGY VIROLOGY RABIES 11

Known TB Patient? Yes, current Yes, former No HIV (Choose nearest location)
Clinical Specimens
30100 Microscopic exam for AFB only
CTS#_________________________ 1300 Decatur
W6000 Waycross
12
30000 Smear, culture & susceptibility testing BITE NUMBER (EPI)
DO NOT USE13500 HIV Ag/Ab Combo
(Susceptibility Performed on MTB only)
30800 Nucleic Acid Amplification Testing (NAAT).
BI/A# __________________________
1360 HIV-1 Ab WB Classification/Species of Animal
This test is intended for use only with specimens from newly
infected patients showing signs and symptoms of active pulmonary 1340 HIV-1 Viral Load Bat
tuberculosis. Cat
AFB Isolates VIRAL CULTURE 13 Dog “Breed” _______________________
34000 Identification 62050 CMV Culture/IFA Fox
33950 Susceptibility testing (MTB only) 62040 Measles Culture/IFA Skunk
30750 Genotyping only 60000 Mumps Culture/IFA Raccoon
PARASITOLOGY 1385 Enterovirus Culture / IFA Other: ___ ___________________
(Choose nearest location) 1330 Herpes Culture / ELVIS Pet Wild Stray
Cryptosporidium 2400 Decatur W5010 Waycross 62000 VZV Culture / IFA COUNTY OF ANIMAL ___________________
6100 Respiratory Culture / IFA Date killed ___ ___________________
Cyclospora 2500 Decatur W5010 Waycross 1375 Influenza Culture / IFA Reason for testing
Other _____________/IFA (mandatory, check all that apply)
Formalin Feces 2100 Decatur W5000 Waycross
60040 Viral Culture / Identification Human exposure
(Please specify) ________________ Bite
PVA Feces 2300 Decatur W5020 Waycross
Contact saliva
Scratch
Pinworm slide 2200 Decatur W5030 Waycross
Gastrointestinal Outbreak Investigation Domestic animal exposure
Bite
2150 PCR 60030 Rotavirus EIA Contact saliva
2710 Tissue/tissue smear for parasites Other ___________________ Scratch
2700 Whole blood/blood smear for parasites - Malaria
Epidemiological Reasons
2710 Whole blood/blood smear for parasites - Filaria
2800 Worm identification Other _______________________
2800 Miscellaneous identification ___ ___________________
All tests are performed at the Decatur Laboratory unless specified.
A correlating list of test and prices is located at http://health.state.ga.us Page 2 of 2 – Form 3583 (Revised 6/28/13)
Instructions for filling in the new DPH Lab Form

Before trying to fill in this new form, the information about the bite incident must be entered into SendSS to
generate the CASE/BITE number needed

1. Mark the lab you are using.

2. Write in your submitter code with no dashes or spaces
3. Write in the CASE/BITE number from the old lab form available by clicking the “Save and Print Lab
Submittal” button in SendSS.
4. For patient information, write in the name and contact information of any human victim involved in the
incident. If no human victim, write in the information for the owner of the domestic animal involved in the
incident. Only if no human victim or animal owner known, should you put the submitter or investigator’s name
in this block.
5. Write in the submitter contact information as it is listed in SendSS. Add the specific name, fax, and phone
number for whom to contact with the test results.
6. Write in the approval code for your county. Every county health department has been assigned a code. Please
contact your county health department if you need this code. Failing to put this code on the form will result in
the DPH lab billing the person or agency submitting the specimen.
7. Add the date the specimen was collected.
8. Add the time the specimen was collected.
9. Mark Refrigerated, as no specimen should be shipped frozen or at room temperature.
10. Write in “Body”, “Head”, or “Brain” for specimen type.
11. Mark the lab you are using, again.
12. Write in the CASE/BITE number from the old lab form from SendSS, again.
13. Mark the boxes that apply to the animal and bite incident.
14. No other information is needed on this form