New Jersey Department of Health

Newborn Screening (NBS) - Billing Unit

P. O. Box 361

Trenton, NJ 08625-0361	ORDER FORM FOR

INITIAL NEWBORN SCREENING REQUEST

(IEM-1) FORMS	Distribution:	ORIGINAL-To be Returned to Requester

COPY-NJDOH, Laboratory File

COPY-To be Retained by Requester
FORM TITLE	QUANTITY	COST PER FORM	TOTAL COST	FOR STATE USE ONLY
Initial Newborn

Screening Request	x $90.00 =	$
Name and Mailing Address of Requester

Make Check/Money Order Payable to:

“NEW JERSEY DEPARTMENT OF HEALTH”
Check/Money Order Number and Date

Ship Date

IEM-15

OCT 14

New Jersey Department of Health

Elaine White

2014-02-12

ewhite

NJDHSS