New York State Non-Permitted Laboratory Test Request Approval Form

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NEW YORK STATE DEPARTMENT OF HEALTH
WADSWORTH CENTER
CLINICAL LABORATORY EVALUATION PROGRAM
EMPIRE STATE PLAZA, PO BOX 509
ALBANY, NY 12201-0509
NEW YORK STATE NON-PERMITTED LABORATORY TEST REQUEST APPROVAL FORM
Justification for requesting use of a facility without a NYS Permit
(Please type or print neatly.)
must be provided in the space below:
Today’s Date: ______________________________
Patient Name: ______________________________
Patient Identifier/#:____________________________
Symptoms/Dx: _______________________________
___________________________________
Gene Name (if applicable): _____________________
___________________________________
Test Requested: _____________________________
___________________________________
Specimen Type: _____________________________
INFORMATION FOR FACILITY MAKING REQUEST/SENDING SPECIMEN:
Name of Facility:__________________________________________________________________________________
Address: ________________________________________________________________________________________
City: _________________________________________________
State: ________
Zip Code: _________________
Contact Person at Facility:__________________________________________________________________________
Phone Number: _________________________________ Fax Number:_____________________________________
PFI#: ___ ___ ___ ___
OR
CLIA#:______________________ ________________
Ordering Physician’s Name: __________________________________________________
Please ensure all information is provided as incomplete forms will not be processed and delay permission for
referral.
INFORMATION FOR LABORATORY PERFORMING TESTING:
Name of Laboratory Director: ________________________________________________________________________
Name of Laboratory or Institution: ____________________________________________________________________
Address:________________________________________________________________________________________
_______________________________________________________________________________________________
City: ________________________________________________
State: ________
Zip code: _________________
Phone Number: _________________________________
Fax Number:_____________________________________
CLIA #: ___________________________________
NYS PFI#: ___ ___ ___ ___ (If applicable)
Genetic Tests to:
Cytogenetic Tests to:
All others to:
Genetic Testing Quality Assurance
Cytogenetics Quality Assurance
Clinical Laboratory Evaluation
Program
Program
Program
Wadsworth Center, NYSDOH
Wadsworth Center, NYSDOH
Wadsworth Center, NYSDOH
Ph: (518) 474-6271
Ph: (518) 474-6796
Ph: (518) 485-5378
Fax: (518) 486-2693
Fax: (518) 486-4921
Fax: (518) 449-6917
Revised 03/05/13

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