The specimen submission form must accompany each specimen.
The patient’s name listed on the specimen must match the patient’s name listed on the form.
If the Date of Collection field is not completed, the specimen will be rejected.
Place DSHS Bar Code Label Here: Place the specimen bar code label that will be used to identify and track the specimen in the DSHS laboratory information management system (LIMS). If you are performing remote entry, place DSHS LIMS specimen bar code label here.
Section 1. SUBMITTER INFORMATION
All submitter information that is required is marked with double asterisks (**).
Submitter/TPI number, Submitter name and Address: The submitter number is a unique number that the Texas Department of State Health Services (DSHS) Laboratory Services Section assigns to each of our submitters. For Texas Health Steps (THSteps) specimens, use the pre-assigned Texas Provider Identifier (TPI) number. To obtain a TPI number and THSteps enrollment, contact Texas Medicaid and Healthcare Partnership (TMHP) at 1-800-925-9126.
To request a DSHS Laboratory Services Section submitter number, a master form, or to change submitter information, please call (888) 963-7111 x7578 or (512) 458-7578, or fax (512) 458-7533.
NPI Number: Indicate the facility’s 10-digit NPI number. All health care providers must use the National Provider Identifier (NPI) number. The NPI number is the new national standard identifier for health care providers adopted by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. To obtain an NPI number, contact the National Plan and Provider Enumeration System (NPPES) toll free at (800) 465-3203 or via their web site at https://nppes.cms.hhs.gov/NPPES/Welcome.do.
Indicate the submitter’s name, address, city, state, and zip code. Please print clearly, use a pre-printed label, or use a photocopy of a master form provided by the Laboratory Services Section.
Contact Information: Indicate the telephone number, name, and fax number of the person to contact at the submitting facility in case the laboratory needs additional information about the specimen.
Clinic Code: Please provide, if applicable. This is a code that the submitter furnishes to help them identify which satellite office submits a specimen and to help the submitter identify where the lab report belongs, if the submitter has a primary mailing address with satellite offices.
Collection Site Information: Complete this information when the collection site is not at the facility requesting the test. Indicate the name, telephone number, and fax number of the person who collected the specimen to contact in case the laboratory needs additional information about the specimen.
Section 2. PATIENT INFORMATION
Complete all patient information including last name, first name, middle initial, address, city, state, zip code, telephone number, country of origin, race, ethnicity, date of birth (DOB), age, sex, social security number (SSN), pregnant, date of collection, time of collection, collected by, medical record number, ICD diagnosis code, and previous DSHS specimen lab number.
NOTE: The patient’s name listed on the specimen must match the patient’s name listed on the form.
Information that is required to bill Medicare, Medicaid, or private insurance has been marked with double asterisks (**). These fields must be completed. You may use a pre-printed patient label.
Date of birth (DOB) and Age: Please list both the date of birth and age of the patient. Please tell us whether the age is in days, months, or years. If date of birth is not provided, specimen may be rejected.
Pregnant: Please indicate if female patient is pregnant by marking either Yes, No, or Unknown. Pregnancy can affect some test results.
Date of collection/Time of collection: Indicate the date and time the specimen was collected from the patient and who collected the specimen. Do not give the date the specimen was sent to DSHS. IMPORTANT: If the Date of Collection field is not completed, the specimen will be rejected.
Medical record number: Provide the identification number for matching purposes.
ICD diagnosis code: Indicate the diagnosis code that would help in processing, identifying, and billing of this specimen.
Previous DSHS specimen lab number: If this patient has had a previous specimen submitted to the DSHS Laboratory, please provide the DSHS specimen lab number.
Section 3. SPECIMEN TYPE
Specimen type: Please indicate the type of specimen that is being submitting.
Section 4. CLINICAL CHEMISTRY
Test Requested: Check or specify the specific test(s) to be performed by the Laboratory Services Section.
Reflex testing (antibody (Ab) identification (ID), antigen (Ag) type, and titer) will be performed on positive antibody screens. Reflex testing will be performed on positive RPR screens.
Lipid Profile, Cholesterol, HDL, and Glucose: The time and date the specimen is removed from FREEZER must be provided to determine specimen acceptability. Please circle FREEZER.
HDN Screening (RhoGAM): The time and date the specimen is removed from the REFRIGERATOR must be provided if the specimen will not be received within 24 hours. Please circle REFRIGERATOR. Do not freeze specimens for HDN testing.
Section 5. PHYSICIAN INFORMATION
Ordering Physician’s name, NPI Number, and UPIN: Give the name of the physician and the physician’s NPI number. Also, list the physician’s unique physician ID number (UPIN), if applicable. Beginning February 2007, UPIN numbers will no longer be issued. The physician’s NPI number will replace the UPIN. This information is required to bill Medicaid, Medicare, insurance, and THSteps.
Section 6. PAYOR SOURCE
THE SUBMITTER WILL BE BILLED, if the required billing information is not provided, is inaccurate, or multiple payor boxes are checked.
Indicate the party that will receive the bill by marking only one box.
Medicaid or Medicare:
- Mark the appropriate box.
- Write in the Medicaid or Medicare number.
- If the patient name on the form does not match the name on the card, the submitter will be billed.
- If Medicare is selected, patient’s DOB and address must be provided.
- Mark the appropriate box.
- Complete all fields on the form that have an asterisk (*).
- If the private insurance information is not provided on the specimen form or is inaccurate, the submitter will be billed.
- If you are contracting and/or enrolled with a DSHS program to provide services that require laboratory testing, please indicate which program. For program descriptions, see the Laboratory Services Section’s Manual of Reference Services located on the web site at http://www.dshs.state.tx.us/lab/prog_desc.htm.
- Do NOT check a DSHS program as a Payor Source if the patient has Medicaid, Medicare, or private insurance.
- If there is no other Payor Source for the patient and the patient meets the program’s eligibility criteria, check the appropriate DSHS program.
- For THSteps, check THStepsas the Payor Source. Write the Medicaid card number in the Medicaid / Medicare Number space.
- For Title V, check Family Planning, Child Health and Dental, or Prenatal Care.
- For BIDS (Border & Infectious Disease Surveillance), EIP (Emerging Infections Program), and ELC (Epidemiology & Laboratory Capacity) programs, check the “Other” box and list the program’s name in the space provided.
HMO / Managed care / Insurance company: Print the name, address, city, state, and zip code of the insurance company to be billed. NOTE: The DSHS laboratories are not an in-network CHIP or CHIP Perinate provider. If CHIP or CHIP Perinate is indicated, the submitter will be billed.
Responsible party: Print the name of the responsible party, the insurance ID number, insurance company’s phone number, group name, and group number.
Signature and Date: Have the responsible party sign and date to authorize the release of their information, if DSHS is to bill their insurance or HMO.
Section 7. NEWBORN REFERENCE TESTING
Test Requested: Check or specify the specific test to be performed by the Laboratory Services Section.
Section 8. DNA ANALYSIS
Select the requested test and provide clinical diagnosis, if available. The genes analyzed are phenylalanine hydroxylase for phenylketonuria testing, β-Globin for hemoglobin testing and galactose-1-phosphate uridyl transferase for galactosemia testing.
For phenylketonuria tests, select either Full Mutation Analysis or Carrier Mutation Analysis.
- Select Full Mutation Analysis to identify any possible mutations.
- Select Carrier Mutation Analysis to test specifically for the mutations already identified in a family member. If submitting a specimen for carrier mutation analysis, please provide the following information on the back of the form: full name of family member(s) who have been tested, their test results, their date of birth, and relationship to the patient. In addition, draw a pedigree showing the relationship and clinical diagnosis of each family member participating in the study.
For all hemoglobin DNA tests, select the box and write the name(s) of the requested tests(s) on the line. Available tests include:
- Hemoglobin S & C mutation test
- Hemoglobin E mutation test
- Hemoglobin D & O-Arab mutation test
- Beta thalassemia -29 and -88 mutation test
- Partial β-Globin sequencing
For specific test instructions and information about tube types, see the Laboratory Services Section Manual of Reference Services.