Laboratory Testing Services Manual - Forms and Laboratory Fee Schedule

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Forms

Fees

If you have trouble viewing any of the documents below, please contact the HHS Accessibility Office, at Accessibility@hhsc.state.tx.us.

Order Forms for Laboratory Mailing Containers and Supplies

Phone (512) 776-7661 
Fax (512) 776-7672

Some of these forms are in PDF format. See the file viewing information. Supplies are provided only for testing performed at the DSHS Laboratory.

Order Forms for Laboratory Mailing Containers and Supplies

Form #

Name

G-6A

Order Form for General Supplies Revised: 08/2018
G-6C Order Form for Gonorrhea/Chlamydia (GC/CT) Laboratory Supplies Revised: 09/2019

G-399

Order Form for Child Health Laboratory Supplies Revised: 08/2018 

G-6D

Order Form for Newborn Screening Supplies Revised: 01/2020  

G-6E

 Order Form for PKU Monitoring Supplies
Medical Providers: To order supplies for PKU Monitoring, contact DSHS Container Preparation Group at 1-888-963-7111 ext. 7661.
Patients: Please contact your metabolic physician or metabolic clinic to get additional PKU Monitoring collection supplies.

G-6F

 Order Form for TB Supplies


Test Request Form Samples and G-9 Form - Laboratory Services

Phone No. (512) 776-7578
FAX No. (512) 776-7533

Note: Unless otherwise noted, these are sample forms only. To receive specimen submission forms with your submitter identification, please request forms by email or by phone. If you do not yet have a submitter identification number, please complete and submit the Submitter Identification (ID) Number Request Form.

When printing out the sample forms below, you may notice that some of the section headings in white type do not print correctly. In that case, choose File > Print from your browser menu, then in the Print dialog box, check the option that says "Print as image." This option is located directly underneath the "Properties" button. Then click the "Ok" button. The sample form should then print normally.

Test Request Form Samples and Master Forms

Form #

Name
  Program Descriptions for Laboratory Forms
  Submitter Identification (ID) Number Request Form, revised: 11/2017 
 Remote Data Services Facility Security Agreement, revised: 4/2020
 Remote Data Services User Agreement, revised: 04/2020 

South Texas Laboratory

F-14 Order Form for General Laboratory Supplies – Sample, revised 02/2020  
F40-A Chemistry Specimen Submission Form – Sample, revised 01/2020

F40-B

F40-B

Microbiology Specimen Submission Form – Sample, revised 01/2020

Spanish Version: Microbiology Specimen Submission Form – Sample, revised 09/2016
F40-C Biothreat Specimen Submission Form – Sample, revised 01/2020 
F40-D Emergency Preparedness Specimen Submission Form – Sample, revised 01/2020
F40-TF40-TB Elimination Specimen Submission- NEW MASTER, revised 01/01/2020
G-1B Biochemistry and Genetics Specimen Submission Form – Sample, revised 01/2020 
G-THSTEPS Texas Health Steps Specimen Submission Form – Sample, revised 01/2020 
G-2A Serology Specimen Submission Form – Sample, revised 01/2020
G-2B Bacteriology and Parasitology Specimen Submission Form – Sample, revised 01/2020
G-2EEpidemiological Studies and CDC Special Projects – Sample, revised 01/2020

G-2V

 Virology Specimen Submission Form – Sample, revised 01/2020
G-2V COVID-19Virology Specimen Submission Sample Form for COVID - 19 Specimens - , 03/2020
G-MYCO Mycobacteriology/Mycology Specimen Submission Form – Sample, revised 01/2020
G-9 Laboratory Test for Rabies – Sample, revised 01/2020
G-14 Mosquito Surveillance Adult/Larval Specimen Submission Form – Sample, revised 01/2020 
G-19 Water Bacteriology Specimen Submission Form – Sample, revised 06/2018 
G-22 Environmental/Fluoride/Microbiological Specimen Submission – Sample, revised 01/2020
G-23 Food Sample Specimen Submission Form – Sample, revised 01/2020
G-27 Biothreat Environmental Specimen Submission Form – Sample, revised 01/2020 
G-27A

Emergency Preparedness Specimen Submission Form – Sample, revised 04/2020 

G27A Instructions - 04/2020

Obtaining Specimen Submission Forms by Email

Email request to: Laboratory Forms. Please provide required information below when requesting forms by email.

Required Information

G-2A or G-2B Microbiology Submission Forms 
The following information is needed to request a G-2A and or G-2B submission form:
  • Submitter Number
  • Submitter National Provider Identification Number (NPI)
  • Provider Name
  • Mailing Address
  • City, State, Zip
  • Phone Number
  • Fax Number
  • Contact person name
  • Physician Name
  • Physician's NPI Number
  • Physician's UPIN Number
  • Email address

G-1B Specimen Submission Form and G-THSTEPS Specimen Submission Form 
The following information is needed to request a G-1B or G-THSTEPS submission form:

  • Texas Provider Identifier Number (TPI)
  • National Provider Identification Number (NPI)
  • Provider Name
  • Mailing Address
  • City, State, Zip
  • Phone Number
  • Fax Number
  • Contact person name
  • Physician Name
  • Physician's NPI Number
  • Physician's UPIN Number
  • Email address

 
Last updated April 23, 2020