4. Submission Form (G-2E) Instructions


Specimen Submission Form Instructions


ALL INFORMATION THAT IS REQUIRED IS MARKED WITH DOUBLE ASTERISKS (**)

   G2E Specimen Submission Form Illustration


Specimen Submission Form Instructions    

 

[correction to instructions found at G2E example form ARLN (state.tx.us)]

Submitter/TPI Number: The submitter number is a unique number the DSHS Laboratory Services Section assigns to each of our submitters. To obtain a Texas Provider Identifier (TPI) number, contact Teas Medicaid and Healthcare Partnership (TMHP) at 1-800-925-9126. To request a DSHS submitter number, a master form, or to update submitter information, please call (888) 963-7111 ext. 7578 or (512) 776-7578, or fax (512) 776-7533. Alternatively, visit 
http://www.dshs.state.tx.us/lab/mrs_forms.shtm#email  
 2NPI Number: Provide the facility’s 10-digit NPI number. All health care providers must use the National Provider Identifier (NPI) number. To obtain an NPI number, contact the National Plan and Provider Enumeration System (NPPES) toll free at (800) 465-3203 or via their website at https://nppes.cms.hhs.gov/NPPES/Welcome.do
 3Submitter Name and Address: Provide the submitter’s name, address, City, State, and zip code. Clearly print, use a pre-printed label, or use a legible photocopy of a master form provided by the Laboratory Services Section.   
 4Phone, Contact and Fax: Provide the name, telephone number, and fax number of the point of contact (POC) at the submitting facility in case the laboratory needs additional information about the specimen or isolate.  
 5Clinic Code: Provide only when applicable. The clinic code identifies the satellite office that submitted the specimen to the submitter. It helps the submitter identify where the lab report belongs in situations when the submitter has a primary mailing address with satellite offices. 
 6ORDERING PHYSICIAN INFORMATION: Provide the name of the physician and the physician’s NPI number. 
 7PAYOR SOURCE: This has been selected as a CDC Special Project by default.
 8PATIENT INFORMATION: Complete ALL required fields in this section. The patient’s first and last name provided on the specimen MUST match the patient’s name on this form. All specimens MUST be labeled with at least two patient-specific identifiers; both a primary and a secondary identifier. Each of the identifiers MUST appear on both the specimen container (or card) and the associated submission form. Specimens that do not meet these identifier requirements will be classified as unsatisfactory for testing. 
 9SPECIMEN SOURCE OR TYPE: Indicate the type of material or the source of the specimen or isolate being submitted. For specimens not described in the list, check the “Other” option, provide details, and initial next to the details.  
 10COLLECTION SITE INFORMATION: Provide the collection site name, infection control contact name, phone number, zipcode and sample number. Include the collection site’s CLIA number, if applicable. 
 11TEST REQUESTED: You MUST identify the specimen as either an isolate or a specimen. Complete Box 1 for isolates only.  Complete Box 2 for specimens for isolation only. Do NOT fill out both Boxes. For isolates, you MUST check the specific test(s) to be performed. To cancel a test marked in error, place a single line through the test name and write “error”. For colonization testing (Box 2), provide the name of the suspected organism. 
Provide copies of any previous laboratory testing of this specimen/isolate to assist DSHS with the identification process. 


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Last updated January 26, 2022