Form Cdph 4453 PDF Details

Form CDPH 4453 is a vital form that healthcare providers use to report abuse, neglect, and exploitation of patients. This form helps the California Department of Public Health investigate allegations of patient mistreatment and protect vulnerable individuals. By understanding the purpose of this form and what information needs to be included, healthcare providers can play a critical role in preventing abuse and protecting patients.

QuestionAnswer
Form NameForm Cdph 4453
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesPNS Order Form WEB revised 1_13 cernx prenatal form

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State of California––Health and Human Services Agency

California Department ofPublic Health

 

Genetic Disease Screening Program

 

California PrenatalScreening Program

REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES

FOR CLINICIANS ONLY

Mailing address:

To Order Supplies:

California Department of Public Health

Toll-free phone: (877) 984

-8450

Prenatal Screening Program Supplies

Toll-free fax: (877) 984

-8650

850 Marina Bay Parkway, F175

email: CernX.sac@cernx.com

Richmond, CA 94804-6403

Clinician’s license number

Last name

First name

Organization/department

Telephone number

Fax number

 

(

)

(

)

 

 

 

 

 

 

 

Address (number, street, suite number)

City

 

State

 

ZIP code

 

 

 

 

 

 

Attention

(Optional) e-mail address forconfirmationand tracking number

Date

•Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO. Order “tubes only” if using other courier service.

•Please use one tray, one pouch, and one box to send one or two specimens if they are drawn the same day.

 

Item Description

Quantity Request ed

 

(Enough for 6-Month Supply)

 

 

First Trimester Prenatal Screening Forms (blue edge)

 

 

 

Second Trimester Prenatal Screening Forms (green edge)

 

 

 

 

Blood Shipping Kit

(Kits contain one 3.5ml serum separator tube (SST), one tray, one pouch, and

 

one box to mail the blood specimen in.)

 

 

 

 

 

For individual items, CIRCLE as needed : TUBES / TRAYS / POUCHES / BOXES

 

 

 

 

Indicate (below) the number of booklets/pamphlets needed in each language:

Prenatal Diagnosis of Birth Defects

English

Spanish

Chinese

Vietnamese

K orean

 

 

 

 

 

Patient Booklet (includes Consent F orm)

 

 

 

 

 

“Easy-to-Read” Pamphlet (as of June 2009 )

*

*

*

 

 

 

 

 

 

 

 

Prenatal Diagnosis of Birth Defects

*

*

*

 

 

 

 

 

 

 

 

Folate pamphlet

 

 

 

“Before and During Pregnancy, You Need Folate”

 

 

 

Prenatal Screening Program

 

 

 

 

Provider Handbook (One per clinician)

 

 

 

 

Important Information About the Newborn

 

 

 

Screening Test (English & Spanish combined)

 

 

 

 

 

 

 

 

Screen Positive Brochures (Distributed to Prenatal Diagnosis Centers for women with screen positive results):

 

Down Syndrome

 

First Trimester

 

 

 

 

* Screen PositiveBooklets in Chinese, Korean,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and Vietnameseas well asother Program

 

 

 

Second Trimester

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

materials may be found on the Program website

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Trimester

 

 

 

 

at:

 

 

Trisomy 18

 

 

 

 

www.cdph.ca.gov/programs/pns

 

 

 

 

 

 

 

 

 

 

 

 

Second Trimester

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How many NEW OB

 

 

Neural Tube Defects or Abdominal Wall Defects

 

 

 

 

 

 

 

 

 

 

patients per month :

 

 

 

 

 

 

 

 

 

 

 

 

Smith-Lemli -Opitz Syndrome

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Large Nuchal Translucency

 

 

 

 

 

 

 

PREGNANCY CALCULATION WHEEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All Prenatal Screening supplies are the property of the State of California. Other use is strictly prohibited.

Allow 2-4 Weeks for Delivery

For Questions and Concerns: CALL (510) 412-1441

CDPH 4453 (1/13)

State of California –– Health and Human Services Agency

California Department of Public Health

 

Genetic DiseaseScreening Program

 

California Prenatal Screening Program

REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES

FOR LABORATORIES AND DRAW STATIONS ONLY

(Clinicians Use Other Side)

Mailing address:

To Order Supplies:

California Department of Public Health

Toll-free phone: (877) 984

-8450

Prenatal Screening Program Supplies

Toll-free fax: (877) 984

-8650

850 Marina Bay Parkway, F175

email: CernX.sac@cernx.com

Richmond, CA 94804 -6403

 

 

Name of laboratory/draw station

Organization/department

Telephone number

Fax number

 

(

)

(

)

 

 

 

 

 

 

 

Address (number, street, suite number)

City

 

State

 

ZIP code

 

 

 

 

 

 

Attention

(Optional) e-mail address for confirmation and tracking number

Date

•Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO Order “tubes only” if using other courier. service

•Please use one tray, one pouch, and one box to send one or two specimens if they are drawn the same day.

 

Item Description

Quantity Requested

 

(Enough for 6-Month Supply)

 

 

Blood Shipping Kit

(Kits contain one 3.5ml serum separator tube (SST), one tray, one pouch, and

 

one box to mail the blood specimen in.)

 

 

 

 

 

 

For individual items, CIRCLE as needed: TUBES / TRAYS / POUCHES / BOXES

Please note:

1.Prenatal Care Provider will complete Part A of the Prenatal Screening Test Request Form.

2.Phlebotomist at laboratory/draw station must complete Part B of the Prenatal Screening Test Request Form.

3.Please photocopy this supply form for future requests.

The California Prenatal Screening Program bills patients directly for the Program fee. Laboratories may bill patients separately a reasonable fee for drawing and handling blood specimens, taking into account that the State Program provides tubes and mailing supplies free of charge to laboratories and draw stations, as well as clinicians.

Reminder: Use only Beckton- Dickinson 3.5ml Serum Separator Tubes (SST) with a gold “vacutainer” top as supplied by the Prenatal Screening Program. Screening test results are based upon calibration for these tubes only .

Important Note: First Trimester specimens MUST be centrifuged or they cannot be analyzed .

Program information and materials may be found on the Program website at:

www.cdph.ca.gov/programs/pns

All Prenatal Screening supplies are the property of the State of California. Other use is strictly prohibited. Allow 2 -4 Weeks for Delivery

For Questions and Concerns: CALL (510) 412-1441

CDPH 4453 (1/13)

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1. Complete the Form Cdph 4453 with a number of major blank fields. Collect all of the necessary information and make sure absolutely nothing is missed!

Part number 1 for filling in Form Cdph 4453

2. The third part is to submit the following fields: Folate pamphlet Before and During, Screen Positive Brochures, Distributed to Prenatal Diagnosis, Down Syndrome, Trisomy, First Trimester, Second Trimester, First Trimester, Second Trimester, Neural Tube Defects or Abdominal, Smith Lemli Opit z Syndrome, Large Nuchal Translucency, PREGNANCY CALCULATION WHEEL, Screen Positive Booklets in, and wwwcdphcagovprogramspns.

Form Cdph 4453 completion process outlined (step 2)

3. This next portion is mostly about California Department of Public, Name of laboratorydraw station, Organizationdepartment, Address number street suite number, Telephone number City, Fax number State, ZIP code, Attention, Optional email address for, Date, Please use Blood Shipping Kits, Item Description, Quantity Request ed, Enough for Month Supply, and Blood Shipping Kit - fill in all these blank fields.

Fax number State, Name of laboratorydraw station, and ZIP code of Form Cdph 4453

Always be very attentive while filling out Fax number State and Name of laboratorydraw station, since this is where a lot of people make mistakes.

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