Newborn Screening Congenital Cytomegalovirus (cCMV) Opt-out Form

Parents and guardians: Submit this form only if you want to remove the Congenital Cytomegalovirus (cCMV) test result from your infant’s newborn screening report.  You can only opt out of the cCMV results until your newborn’s screening report is complete. The report is usually complete 5-7 days after their birth. Forms received after the report has been completed cannot be accepted.

For more information, click here or refer to the brochure entitled ‘Newborn Screening for Cytomegalovirus (CMV): A new test for all babies’ that the birth hospital provided with your baby’s newborn screening paperwork (pink slip). 
Newborn screening LABID number. The LABID is a 9-digit number listed at the top left on your baby's pink newborn screening slip. If you do not have the LABID from the pink slip, it is very important that you carefully enter all information about your baby below and double check it before you hit ‘Submit’ below. The Submit button will not work if the LabID is not correct.
Name of the hospital where your baby was born, OR if born at home type ‘Home’ and enter the name of your birth attendant/midwife.
Date your baby was born (MM/DD/YYYY).
Biological sex assigned at birth.
Birth mother's date of birth (MM/DD/YYYY).
Birth mother's first name.
Birth mother's last name.
Please enter your 9-digit phone number.
Your email address. Having your email is helpful so we can contact you if we cannot locate your baby's newborn screening records from the information submitted.

10. Check the box below to verify that you choose to opt out of your baby's CMV screening report. By entering your name above (#6 and #7) and checking the box below, you are confirming that:
(1) You are choosing to opt your baby out of the CMV report, and
(2) You are a parent or legal guardian of this baby, and
(3) You understand opting out means that CMV screening results will not be included in your child's newborn screening report, even if the result is positive. 

Enter today's date.
Questions or Problems?
For any questions or problems filling out or submitting this form, please contact the New York State Newborn Screening Program by phone: 518-473-7552 or email:
Submit button will not work if LabID is incorrect.