California Newborn Screening -- Follow-Up Lab Evaluations Date:
Patient: DOB:
Dear Doctor ,
We have results on your patient, referenced above, requested as follow up on an abnormal newborn screening:
q Plasma acylcarnitine profile results are □ within normal ranges □ abnormal □ equivocal
q Plasma amino acids results are □ within normal ranges □ abnormal □ equivocal
q Urine organic acids results are □ within normal ranges □ abnormal □ equivocal
q Plasma total homocyst(e)ine results are □ within normal ranges □ abnormal □ equivocal
q Plasma carnitine results are □ within normal ranges □ abnormal □ equivocal
Recommended follow-up at this time includes the following checked items:
q No follow is necessary, initial abnormality was due to transient variability of newborn
q Please repeat the following :
q Plasma acylcarnitine profile / q Plasma amino acids / q Urine organic acids, comprehensiveq Plasma carnitine / q Plasma total homocyst(e)ine / q Other:
The attached laboratory requisition form must be included to assure proper handling of the specimens required above. Please send the Quest Test Request Form with the specimens; schedule Quest to pick up samples, or find a Quest Patient Center by calling 1-800-522-8378.
If the specimen is sent to a laboratory other than Quest Diagnostics please fax the confirmatory results to Jan Panyard-Davis, RN, at 619-471-9570.
Please feel free to call if there are any questions, or to discuss this case. You can reach us by asking for the Pediatric Metabolic On-Call Physician through Children’s Hospital of San Diego (858-576-1700) or UCSD (619-543-6737).
Sincerely,
Biochemical Genetics- Division: UCSD and Children’s Hospital, San Diego
Bruce A. Barshop, MD, PhD William L. Nyhan, MD, PhD Mary Willis, MD, PhD
Richard H. Haas, MD Fred Levine, MD, PhD
BILLING INFORMATION
As a matter of law, patients’ families must not be billed for testing, blood sampling, shipping, or any other activity associated with newborn screening or confirmation. The UCSD Metabolic Center (California Region V Follow-up Center) will be responsible for billing laboratory test fees to third party payers (including CCS). In that case, the Primary Care Provider (PCP) or patients will not be financially responsible for these follow-up services.