Revised G-1B and F40 Specimen Submission Forms

State of Texas Seal

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

DAVID L. LAKEY, M.D.
COMMISSIONER

1100 W. 49^th Street • Austin, Texas 78756
P.O. Box 149347 • Austin, TX 78714-9347
1-888-963-7111 • http://www.dshs.state.tx.us
TDD: 1-800-735-2989

March 10, 2008

Dear Submitter:

RE: Revised G-1B and F40 Specimen Submission Forms

Effective April 2008, the Texas Department of State Health Services (DSHS) Laboratory Services Section will be changing the G-1B and F40 specimen submission forms.

Enclosed you will find a new master copy of the new Specimen Submission forms and a copy of the form’s instructions. Please be aware that the Ordering Physician’s name and National Provider Identifier (NPI) number must be provided in Section 5. Please verify that your submitter information on the Specimen Submission forms is correct and up-to-date. If it is not, please fax the Specimen Submission form with the needed corrections to (512) 458-7533. Discard all old TDH/DSHS Laboratory forms that are listed below:

OLD FORM	Comments
G-1B (MAR 2006) Rev 6	Replaced with G-1B (APR 2008) Rev 7
F40-11036 (SEP 2006) Rev 1	Replaced with F40-A (APR 2008) Rev 2
F40-B (SEP 2007) Rev 2	Replaced with F40-B (APR 2008) Rev 3

The new forms are:

NEW FORM	Comments
G-1B (APR 2008) Rev 7	for Biochemistry and Genetics specimens
F40-A (APR 2008) Rev 2	for South Texas Laboratory (STL) chemistry specimens
F40-B (APR 2008) Rev 3	for STL microbiology specimens

If you have any other questions and/or comments, please contact Susan Hoffpauir at 1-888-963-7111 ext. 6030. Thank you for your continued support.

Sincerely,

Susan U. Neill, PhD, MBA
Director, Laboratory Services Section