To decline the heel-prick blood test in Texas, you complete the Texas newborn screening refusal form, officially titled the “Newborn Screen Blood Test Refusal Form” and issued by the Texas Department of State Health Services (DSHS). It’s available in English and Spanish on the DSHS website, and the signed original is filed in your baby’s medical record. State law only allows refusal on religious grounds, so the form itself asks you to affirm that basis before you sign.
Who Can Sign It
Texas Health and Safety Code § 33.012 recognizes one reason for opting out: the screening conflicts with the religious tenets or practices of an organized church you belong to. There is no general “reasons of conscience” exemption for newborn screening, unlike some other Texas health exemptions such as childhood immunizations. Philosophical or personal objections are not authorized bases.
Only the newborn’s parents, managing conservator, or legal guardian can sign the refusal. A grandparent, doula, or family friend cannot. The refusal covers both required specimens: the first, collected between 24 and 48 hours after birth, and the second, collected between one and two weeks of age.
Where to Get the Form
DSHS publishes the standardized form, last revised in June 2024, on its Newborn Screening FAQ page. From dshs.texas.gov, follow Laboratory Services → Newborn Screening → FAQs, where you’ll find the English and Spanish versions.
The DSHS form isn’t the only accepted document. A provider can use a self-developed form as long as the refusal is properly recorded in the child’s medical record and the parent signs the entry. Most hospitals and birthing centers use the DSHS version because it has built-in acknowledgment statements and a tear-off submitter section designed to be returned to the state lab. Using the official form removes any question about whether the refusal was documented correctly.
Filling Out the Form
Before you complete anything, the healthcare provider is supposed to explain what newborn screening is for, share an educational video (linked via a QR code on the form), and answer your questions. The form is meant to be the last step after that discussion, not a way around it.
If you still decline, the form asks you to check three acknowledgment statements:
- “I have heard the benefits of the newborn screening blood test.” This confirms the provider educated you about what the test detects.
- “I know I can only refuse this test if it is against the teachings or practices of my church.” Checking this box affirms your refusal rests on religious grounds, as § 33.012 requires.
- “I do not want my baby tested now. I will take a copy of this form to show to my baby’s doctor.” This acknowledges that you’ll carry documentation forward to later providers.
Under the checkboxes, fill in the baby’s medical record number, which the hospital assigns. Then sign, date, and print your name. The healthcare staff member who walked you through the discussion also signs, dates, and prints their name. There is no witness signature and no notarization.
The bottom of the form has a separate submitter section: facility name, DSHS-assigned submitter ID number, city, state, zip code, and date. Hospital staff complete that part, not the parent.
What Happens to the Form After You Sign
Three things happen once the form is complete:
- The original stays in the baby’s medical record at the birthing facility. It documents that the parent declined screening and protects both the parent’s decision and the facility’s compliance record.
- A copy goes to you. Staff photocopy or print a duplicate. Bring it to the baby’s first pediatric visit so the pediatrician sees that screening was formally declined rather than simply missed.
- The bottom tear-off portion goes to DSHS. Staff detach the submitter section and return it with their regular newborn screening specimen shipments. That’s how the state tracks refusals.
Present the form early. Ideally, hand it over at admission or as soon after delivery as practical, because the first specimen is normally collected between 24 and 48 hours of age. The clinical team needs to know before that window opens.
The Second Screening
Texas requires two blood specimens. The first is collected between 24 and 48 hours after birth, and the second between one and two weeks of age, with a minimum of 168 hours between collections. The refusal form you sign at the hospital covers the initial screening, but the second specimen is typically collected at a separate visit, often by the pediatrician or at a follow-up clinic.
Bring your copy of the signed refusal form to that appointment. The pediatrician’s office will note the refusal in the ongoing medical record. If the provider at the second visit doesn’t have documentation of your original refusal, they are still obligated to offer the screening as part of standard care. Having the form in hand prevents the test from being performed simply because no one knew it had already been declined.
Home Births and Midwife-Attended Deliveries
The screening requirement and the refusal process apply regardless of where the baby is born. Under 16 Texas Administrative Code § 115.120, a licensed midwife must either collect the blood specimen or obtain a completed and signed objection form from any parent who refuses. The midwife is responsible for ensuring the form is properly documented, just as a hospital would be.
The practical difference is logistics. A midwife attending a home birth needs specimen collection kits and refusal forms on hand ahead of time. If you’re planning a home birth and intend to decline, discuss this with your midwife before your due date so the correct form is available during the delivery.
Blood Spot Storage Is a Separate Form
If you’re refusing the test entirely, blood spot storage isn’t relevant to you: there are no specimens to store. The “Storage and Use of Newborn Screening Blood Spots” form only applies to families who go through with screening but want to control how long the leftover dried blood spots are kept. By default under Health and Safety Code § 33.018, the DSHS lab stores residual dried blood spots for up to two years and then destroys them; parents can opt in to longer storage of up to 25 years. Don’t confuse this document with the refusal form.