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Form 197 Revised 9/2016 KY Division of Laboratory Services 100 Sower Blvd. North Loading Dock P. O. Box 2020 Frankfort Kentucky 40602-2020 Phone 502/564-4446 Fax 502/564-7019 Jeremy Hart MD FCAP Director Human Immunodeficiency Virus Serology Assigned Code No. Please complete a separate form for each specimen. K Y PATIENT INFORMATION Name Last First MI Social Security Sex Race Age Birthdate Home Address City State Zip Code County Send Report To Submitter Street Address PO BOX Specimen...
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