Newborn Screening Program Forms

Most commonly used forms

• To receive a copy of your child’s newborn screening results, please complete and return CDPH Form 4408, Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF), to NBS@cdph.ca.gov (see below for Spanish version). 

For families

​Many parents want their baby's blood spot used for newborn screening to be stored. The benefits of storing the blood spot are many. Some parents want their baby’s blood spots destroyed after newborn screening. The reasons why parents amy or may not want their baby’s blood spots destroyed are explained on the NBS Program My Baby’s Blood Spots web page. ​

Forms if parents want to have a baby’s blood spots destroyed:

• CDPH 4410 (English): Parent Request to Have Newborn Blood Specimen Card Destroyed (PDF)
• CDPH 4410 (Spanish): Solicit​ud Para Los Padres Para Destruir La Tarjeta de Muestra de Sangre del Recién Nacido (PDF)​

Effective May 1, 2023, the NBS program has retired and discontinued all PDF and paper copies of the Newborn Screening (NBS) Provider Supply Order Form for Hospital & Out-of-Hospital Providers (CDPH Form 4010). 

Please use the online NBS supply order portal instead, and always include your provider or hospital/facility code to avoid delays.

• CDPH Form 4408: Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF, English)
• CDPH Form 4408: Consentimiento Para La Divulgación y / o Divulgación de Información Confidencial de GDSP (PDF, Spanish)
• CDPH Form 4400: Request for NBS Program Hemoglobin Results (PDF, English)
• ​​CDPH Form 4407: Consent for Release of Dried Blood Specimen from GDSP (PDF, English)
• CDPH Form 4407: Consentimiento Para La Liberación de Muestras de Sangre Seca de GDSP (PDF, Spanish)
• CDPH Form 4410: Parent Request to Have Newborn Blood Specimen Card Destroyed (PDF, English)
• CDPH Form 4410: Solicit​ud Para Los Padres Para Destruir La Tarjeta de Muestra de Sangre del Recién Nacido (PDF, Spanish)​
• CDPH Form 9130 : Patient Request to Have Newborn Blood Specimen Card Destroyed (PDF, English)

For p​roviders

Effective May 1, 2023, the NBS program has retired and discontinued all PDF and paper copies of the Newborn Screening (NBS) Provider Supply Order Form for Hospital & Out-of-Hospital NBS Providers (CDPH 4010). Please use the online NBS supply order portal instead, and always include your provider or hospital/facility code to avoid delays.​

• CDPH Form 4406: Newborn Screening Transport Log (PDF, English)
  
• CDPH Form 4408: Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF, English)
  
• CDPH Form 4408: Consentimiento Para La Divulgación y / o Divulgación de Información Confidencial de GDSP (PDF, English)
  
• CDPH Form 4410: Parent Request to Have Newborn Blood Specimen Card Destroyed (PDF, English)
• CDPH Form 4410: Solicit​ud Para Los Padres Para Destruir La Tarjeta de Muestra de Sangre del Recién Nacido (PDF, Spanish)​
  
• CDPH Form ​9130: Patient Request to Have Newborn Blood Specimen Card Destroyed (PDF, English)​