The Missouri Department of Health and Senior Services provides vital resources for healthcare and public health testing through its State Public Health Laboratory by offering the MO 580 0764 form. This requisition form is essential for approved sites to request laboratory specimen kits necessary for a wide range of tests, including newborn screening and tests for various infectious diseases like gonorrhea, chlamydia, syphilis, HIV, tuberculosis, and even water-borne bacteria. Designed to streamline the process of obtaining testing supplies, the form details the availability and cost of specific kits, such as swab collection kits for sexually transmitted infections, hemoglobin test kits, and environmental testing kits for lead in blood, dust, soil, and water. Moreover, the form underscores the laboratory's commitment to providing services equitably, including information about courier services for free specimen transport, highlighting the effort to make health testing services accessible and efficient across Missouri. This form, updated in April 2014, stands as a crucial tool in the public health infrastructure, ensuring that entities can securely order the necessary supplies to conduct public health surveillance, diagnose conditions early, and implement timely interventions.
| Question | Answer |
|---|---|
| Form Name | Form Mo 580 0764 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | OrderForm missouri department health request form immunology |
MISSOURI DEPARTMEnT OF HEALTH AnD SEnIOR SERVICES STATE PUBLIC HEALTH LABORATORy
REQUISITION FOR LABORATORY SPECIMEN KITS |
101 n. CHESTnUT JEFFERSOn CITy, MO 65101
(573)
To obtain information regarding test requisition forms or to find a courier stop for free specimen transport, go to www.health.mo.gov/lab. Please call (573)
NEWBORN SCREENING |
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IMMUNOLOGY– **Test Request Form Available Online |
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Filter Paper - Initial Form ($65.00) |
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YOU MUST BEANAPPROVED SITE |
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Filter Paper - Repeat Form ($65.00) |
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Swab Collection Kit for Endocervical, Male Urethral, Rectal, |
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Envelopes |
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Pharyngeal (Gonorrhea/Chlamydia) |
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Listing Pads |
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Urine Collection Kit (Gonorrhea/Chlamydia) |
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Vaginal Swab Collection Kit (Gonorrhea/Chlamydia) |
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Hemoglobin Test Kit, Finger/Heel Stick (Child) |
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Gonorrhea/ChlamydiaMailer[1’s |
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Hemoglobin Test Kit, Venous Blood (Adult) |
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Gonorrhea/Chlamydia Prepaid Envelope |
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Syphilis (RPR) and/or HIV Antibody Kit |
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MICROBIOLOGY– **Test Request Form Available Online |
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Enteric Kit Complete Kit (For Feces) |
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Enteric Kit (For Feces) Components Only |
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VIROLOGY– **Test Request Form Available Online |
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Cary Blair Media |
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Virus Isolation Kit |
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Enteric/Special Bacteriology Kit Double Wall Mailing Containers |
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Virus Isolation Kit - Rash Kit (Unknown Rash) |
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(For Culture) |
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Virus Isolation Kit - Seasonal Influenza Surveillance Kit |
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Scabies Kit |
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Virus Isolation Kit - Respiratory (Avian Flu) |
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Bordetella Pertussis Complete Kit (Whooping Cough) |
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Virus Isolation Kit - Mumps |
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Bordetella Pertussis (Whooping Cough) Components OnLy |
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Hepatitis Screening Kit |
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Media |
Saline |
Media & Saline |
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Viral Serology Kit |
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Intestinal Parasites Kit |
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(Measles, Rubella, Arbovirus, Rickettsial, West nile) |
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Gastrointestinal Outbreak Kit (Includes norovirus) |
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CHEMISTRY |
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TUBERCULOSIS – **Test Request Form Available Online |
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Blood Lead - Complete Capillary Kit |
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AFB for Clinical Specimens (Category B mailer) |
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Blood Lead - Capillary Kit Individual Components |
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AFB Reference Culture (Category A mailer) |
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Device |
Sticker |
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Mailer |
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Blood Lead - Venous Kit |
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Lead Testing Dust Wipes |
Soil Kit Paint Kit |
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Cubitainers (For Water Collection) |
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ENVIRONMENTAL |
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Drinking Water Kit (For Bacteria) - Private |
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Complete Kit Forms Only |
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Drinking Water - Official (Forms Only) |
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Recreational Water Kit |
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COnTACT nAME
TELEPHOnE nUMBER
LAB USE ONLY
FACILITy nAME
DATE ORDER RECEIVED
ADDRESS (STREET, CITy, ZIP) [STREET ADDRESS REQUIRED FOR UPS DELIVERy]
DATE ORDER SHIPPED
MO |
An EQUAL OPPORTUnITy/AFFIRMATIVE ACTIOn EMPLOyER |
LAB 19 |
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services provided on a nondiscriminatory basis |
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