Revised G-1B, G-1C, G-2A, G-2B, F40-A, and F40-B 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

August 11, 2008

Dear Submitter:

RE: Revised G-1B, G-1C, G-2A, G-2B, F40-A, and F40-B Specimen Submission Forms

Effective September 2008, the Texas Department of State Health Services (DSHS) Laboratory Services Section will be changing the G-1B, G-1C, G-2A, G-2B, F40-A, and F40-B specimen submission forms, including changes in the Payor Source sections.

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 the Ordering Physician Information section. 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 DSHS Laboratory specimen submission forms that are listed below:

OLD FORM	Comments
G-1B (APR 2008) Rev 7	Replaced with G-1B (SEP 2008) Rev 8
G-1C (MAR 2006) Rev 2	Replaced with G-1C (SEP 2008) Rev 3
G-2A (MAR 2006) Rev 1	Replaced with G-2A (SEP 2008) Rev 2
G-2B (MAR 2006) Rev 1	Replaced with G-2B (SEP 2008) Rev 2
F40-A (APR 2008) Rev 2	Replaced with F40-A (SEP 2008) Rev 3
F40-B (APR 2008) Rev 3	Replaced with F40-B (SEP 2008) Rev 4

The new specimen submission forms are:

NEW FORM	Comments
G-1B (SEP 2008) Rev 8	for Biochemistry and Genetics specimens
G-1C (SEP 2008) Rev 3	for Maternal Serum Prenatal Triple Screen specimens
G-2A (SEP 2008) Rev 2	for Serology and Virology specimens
G-2B (SEP 2008) Rev 2	for Bacteriology and Parasitology specimens
F40-A (SEP 2008) Rev 3	for South Texas Laboratory (STL) Chemistry specimens
F40-B (SEP 2008) Rev 4	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