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 to OS2 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 7/20/2015
Please supply the following information (required designated by *):
Please supply the following information (required designated by *):
What type of sample was submitted?*
What type of sample was submitted?*
Clinical Samples
Clinical Samples
Environmental Samples
Environmental Samples
Check if you need a copy of your original submission form sent to you.
Check if you need a copy of your original submission form sent to you.
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.