Alaska Newborn Bloodspot Screening Authorization Form

Submit the completed form to the Alaska Newborn Bloodspot Screening Program via the following methods: Email: newbornscreening@alaska.gov Fax: 907.754.3455 Mail: Alaska Department of Health and Social Services, Division of Public Health, Section of Women's, Children's, and Family Health, 3601 C Street, Suite 322, Anchorage, Alaska 99503. Make sure to retain a copy of the submitted form for your records.

Important dates for this form in 2024 and 2025 include the expiration date entered by the parent or client representative. Additionally, authorization forms must be retained for six years from the date of signature.

The purpose of the Alaska Newborn Bloodspot Screening Authorization Form is to facilitate the release of a child's dried bloodspot for various approved uses. This form ensures that the release is conducted with parental consent and meets specific criteria to protect the child's privacy and health information. By using this form, parents and authorized representatives can request the release of the bloodspot for medical analysis, legal purposes, or research, provided that the request adheres to the program's guidelines. The form also includes provisions for revoking the authorization, offering flexibility and control to parents and representatives. Overall, this form is a crucial tool for managing the secure and authorized release of sensitive health data represented by the dried bloodspot.

• 1. Child's Name: Enter the full name of the child whose bloodspot is being released.
• 2. Date of Birth: Enter the child's date of birth to help identify the record.
• 3. Lab Number: Provide the lab number associated with the child's bloodspot.
• 4. Other Names Under Which Records Might Be Filed: List any other names that might be used to file the records.
• 5. Organization Releasing Dried Bloodspot: Pre-filled as 'Alaska Newborn Bloodspot Screening Program'.
• 6. Person/Organization Requesting and Receiving Dried Bloodspot: Enter the name and address of the entity requesting and receiving the bloodspot.
• 7. Address for receipt of bloodspot: Provide the address where the bloodspot should be sent.
• 8. Purpose of the release of this dried bloodspot: Specify the purpose of releasing the bloodspot.
• 9. Expiration Date/Event: Enter a date or event marking the expiration of this authorization.
• 10. Signature of Parent or Personal Representative: Signature of the parent or representative authorizing the release.
• 11. Date: Date on which the form is signed.
• 12. Printed Name of Personal Representative or Witness: Printed name of the person signing the form or witness.
• 13. Description of Personal Representative's Authority: Detail the authority of the representative signing on behalf of the parent or child.

If you fail to submit this form, the requested bloodspot will not be released. This could affect any ongoing medical, legal, or research processes that require the bloodspot.

• Medical delays: Delays in accessing the bloodspot may hinder necessary medical analysis.
• Legal complications: Failure to release the bloodspot could cause issues in legal proceedings or adoptions.
• Research halt: Any approved research requiring the bloodspot may be unable to proceed.

• 1. Medical Analysis: To request the bloodspot for further medical testing.
• 2. Legal Purposes: Needed in legal situations, such as custody or adoption cases.
• 3. Parental Request: Parents may request the bloodspot for personal records or peace of mind.
• 4. Research: Researchers can use the bloodspot for studies, with parental consent.
• 5. Authority Requirement: Required by an authority figure for certain processes or investigations.