Mailing and specimen packaging information
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.
DSHS Receiving Laboratory: Please mark the box next to the laboratory that you will be shipping the specimen.
To obtain a copy of the specimen report, please contact the laboratory that you submitted the specimen. The telephone numbers are listed on the form.
Section 1. SUBMITTER INFORMATION
All submitter information is required.
Submitter/TPI number, Submitter name and Address: 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.
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.
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.
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 laboratory report belongs, if the submitter has a primary mailing address with satellite offices.
Section 2. PATIENT INFORMATION
Complete all patient information including last name, first name, middle initial, address, city, state, zip code, country of origin, race, ethnicity, date of birth (DOB), age, sex, social security number (SSN), date of collection, time of collection, patient ID number, 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 (**). 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. If date of birth is not available, give the age of the patient and tell us whether the age is in days, months, or years.
Date of Collection/Time of Collection: Indicate the date and time the specimen was collected from the patient or other source and who collected the specimen. Do not give the date the specimen was sent to DSHS. If the Date of Collection field is not completed, the specimen will be rejected.
Patient ID Number: Provide the identification number for matching purposes.
Previous DSHS Specimen Lab #: If this patient has had a previous specimen submitted to the DSHS Laboratory, provide the DSHS specimen laboratory number.
Country of Origin: If the patient’s country of origin is not the U.S., then please provide the patient’s country of origin.
Section 3. TEST
Test Requested: For specific test instructions, see the Laboratory Services Section Manual of Reference Services
Section 4. PHYSICIAN INFORMATION
Physician’s name and UPIN: Give the name of the physician and their unique physician ID number (UPIN), if applicable.
Section 5. PAYOR SOURCE
Indicate the party that will receive the bill. THE SUBMITTER WILL BE BILLED, if the required billing information is not provided.
Checking Medicaid or Medicare:
- Write in the Medicaid or Medicare number, and
- Supply a copy of the Medicaid or Medicare card.
Checking Private Insurance:
- Supply a copy of the front and back of the insurance card, and
- Complete all fields on the form that have an asterisk (*).
Checking a DSHS Program:
- If there is no other Payor Source for the patient, check the DSHS Newborn Screening Case Management program.
HMO / Managed care / Insurance company: Print the name, address, city, state, and zip code of the insurance company to be billed.
Responsible party: Print the name of the responsible party, the insurance ID number, insurance company’s telephone 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.
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