Free 07859.FH11 - Indiana

Mail this Form to:

AUTHORIZATION / REQUEST FOR PATERNITY BLOOD TEST
State Form 7859 (R5 / 11-06) / CSB 0435

Claims Payment Family and Social Services Administration PO Box 28, MS 36 Indianapolis, IN 46206-0028

INSTRUCTIONS:

To be completed and signed by Prosecuting Attorney and forwarded, with Child Support Bureau approval for payment, to the provider named below. The provider is to submit this fully completed form and an invoice to the address listed above for payment of this invoice.
This state agency is requesting disclosure of your Social Security number in order to expedite processing of this form. Disclosure is MANDATORY pursuant to 42 USC 666 (a) (13). Records in this series are CONFIDENTIAL per 42 USC 653, 42 USC 654, and 42 USC 663.

County of Prosecuting Attorney Name of medical services provider Street address City, state, and ZIP code Indiana ISETS case number

REQUESTED SERVICES Perform DNA test Draw blood samples Other (specify)

Ship blood samples to: (name)
Street address City, state, and ZIP code

You are requested to provide the above indicated medical services for the individuals listed below to assist in the determination of paternity for the child named.
INDIVIDUALS FOR WHOM PAYMENT HAS BEEN AUTHORIZED
Name of child's mother Name of child Name of child Name of putative father Name of putative father Comments

Social Security number Social Security number Social Security number Social Security number Social Security number

Upon completion of the services requested, you are hereby authorized to submit billing to the Indiana Family and Social Services Administration for payment by the Indiana Department of Child Services, Child Support Bureau, for these services.
CERTIFICATION

I certify that I am the duly authorized agent of the Indiana Department of Child Services, Child Support Bureau, in IV-D paternity matters in this jurisdiction. I further certify that these services have been requested pursuant to a court order or an agreement between the parties in a IV-D paternity case, and these services are necessary to carry out my obligation pursuant to the terms of a cooperative agreement between this jurisdiction and the Indiana Department of Child Services, Child Support Bureau.
Signature of authorized agent Title Date signed (month, day, year)