DCH-0558 (Rev. 4-19) 1 Previous edition obsolete. ENVIRONMENTAL LEAD TEST REQUISITION MDHHS USE ONLY Michigan Department of Health and Human Services Date Received @ MDHHS Initials Bureau of Laboratories – Trace Metals Unit PO Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, MI 48909 Phone: 517-335-8059 Fax: 517-335-9871 Web: www.michigan.gov/mdhhslab Print in UPPERCASE using dark pen SUBMITTER INFORMATION Submitter Clinic Code Submitter/Agency SITE INFORMATION Address Apartment # City State Zip Code MDHHS USE ONLY - PAYMENT Medicaid/CHIP/SPA HUD GF Flint Supplemental Other SAMPLE INFORMATION – INDICATE SAMPLE TYPE Collection Date (MM-DD-YY) Dust Wipes Soil Food EBL Same Day Testing
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Environmental Lead Test Requistion - Michigan · ENVIRONMENTAL LEAD TEST REQUISITION CHAIN OF CUSTODY Released By Released To Date Released By Released To Date Released By Released
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DCH-0558 (Rev. 4-19) 1 Previous edition obsolete.
ENVIRONMENTAL LEAD TEST REQUISITION MDHHS USE ONLY
Michigan Department of Health and Human Services Date Received @ MDHHS Initials
Bureau of Laboratories – Trace Metals Unit
PO Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, MI 48909
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.