Amended Information for Submitted SamplesIdaho Bureau of Laboratories

Amended Information for Submitted Samples

Idaho Bureau of Laboratories

Please complete the following form to amend information for previously submitted sample(s).

Office Use Only: IBL staff, please complete the information below and submit completed form for HCM upload.

IBL Staff Name: ________________________________________ Lab ID, if not provided on form: ___________________________

Date changes made in Horizon: ___________________________ Date uploaded to HCM: __________________________________

This is a secure web site. Data sent on this form will be encrypted and meets HIPAA guidelines/standards. The information will be used solely by Idaho Bureau of Laboratories (IBL) and only in relation to testing and resulting of samples submitted for analysis.

Revised 11/15/2022

Please supply the following information (required designated by *):

Your name*

Telephone*

Email address*

Fax

Sample or patient ID, if known

IBL's lab sample ID (e.g., E150700987-002), if known

What type of sample was submitted?*

	Clinical sample (e.g., blood, stool, swab, rabies, food, etc.)
	Environmental sample (e.g., water, soil)

Clinical Samples

Facility name

Patient name

Date sample was collected

Environmental Samples

Public Water System ID, if applicable

Location

Date sample was collected

Time sample was collected (e.g., 5:00 PM)

Check if you need a copy of your original submission form sent to you.

	Fax
	Email

If you need to add another test or procedure for the sample, please describe it here.

If you need to amend information submitted with the sample (such as correcting a sample ID, date of birth, spelling of patient name, location, etc.), please provide the original and updated information here.

Please provide any other comments that may be relevant.