ENROLLMENT CONFIRMATION

Transcription

1 Step 1: Please review the Facility/Contact information. If any of the information is incorrect, please make the appropriate changes below: Facility/Contact Phone: (850) Fax: (850) N W St (primary): michael.gaudet@hcahealthcare.com Pensacola, FL, UNITED STATES, (secondary): carolandme@cox.net (Please add pt@aafp.org to your electronic address book) CLIA ID: 10D Lab Director: Michael E Kasabian COLA ID: Attention: Mike Gaudet JCAHO ID: STATE ID: FL; Step 2: AAFP-PT PT Central Login Information: Login: ; Password: You will report your results online at using login name and password provided above. You will receive your evaluation electronically via the * address on file. * We must have a valid address in order for you to report online and to receive your evaluation. Step 3: Confirm that the Modules and Events list is correct and complete. If the Modules are correct, confirm that the test selection includes all the tests required for your laboratory. If the test selection is correct, confirm that your instrument/kit and reagent information for each analyte is correct. If any information is incorrect, please contact AAFP-PT immediately by to pt@aafp.org. Module Instrument/Kit Year Event / Status Test / Reagent / Decimal MultiChem A / Active Free T4 (in ng/dl) / NONE / 2 Albumin (in g/dl) / NONE / 1 Alkaline Phosphatase (in IU/L) / NONE / 0 ALT/SGPT (in IU/L) / NONE / 0 Amylase (in IU/L) / NONE / 0 AST/SGOT (in IU/L) / NONE / 0 Bilirubin Direct (in mg/dl) / NONE / 2 Bilirubin Total (in mg/dl) / NONE / 1 Calcium (in mg/dl) / NONE / 1 Chloride (CL-) (in mmol/l) / NONE / 0 Cholesterol HDL (in mg/dl) / NONE / 0 Cholesterol LDL (in mg/dl) / NONE / 0 Cholesterol Total (in mg/dl) / NONE / 0 CO2 (Total CO2 Bicarb) (in mmol/l) / NONE / 0 Creatine Kinase (in IU/L) / NONE / 0 Creatinine (in mg/dl) / NONE / 2 GGT (in IU/L) / NONE / 0 Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:1

2 Glucose (in mg/dl) / NONE / 0 Iron (in ug/dl) / NONE / 0 LDH (in IU/L) / NONE / 0 Lipase (in U/L) / NONE / 0 Magnesium (in mg/dl) / NONE / 1 Phosphorous (in mg/dl) / NONE / 1 Potassium (K+) (in mmol/l) / NONE / 1 Sodium (NA+) (in mmol/l) / NONE / 0 TIBC (in ug/dl) / NONE / 1 Total Protein (in g/dl) / NONE / 1 Triglycerides (in mg/dl) / NONE / 0 Triiodothyronine (T3) (in ng/ml) / NONE / 1 TSH (in uu/ml) / NONE / 2 Urea Nitrogen (BUN) (in mg/dl) / NONE / 0 Uric Acid (in mg/dl) / NONE / 1 MultiChem B / Active Free T4 (in ng/dl) / NONE / 2 Albumin (in g/dl) / NONE / 1 Alkaline Phosphatase (in IU/L) / NONE / 0 ALT/SGPT (in IU/L) / NONE / 0 Amylase (in IU/L) / NONE / 0 AST/SGOT (in IU/L) / NONE / 0 Bilirubin Direct (in mg/dl) / NONE / 2 Bilirubin Total (in mg/dl) / NONE / 1 Calcium (in mg/dl) / NONE / 1 Chloride (CL-) (in mmol/l) / NONE / 0 Cholesterol HDL (in mg/dl) / NONE / 0 Cholesterol LDL (in mg/dl) / NONE / 0 Cholesterol Total (in mg/dl) / NONE / 0 CO2 (Total CO2 Bicarb) (in mmol/l) / NONE / 0 Creatine Kinase (in IU/L) / NONE / 0 Creatinine (in mg/dl) / NONE / 2 GGT (in IU/L) / NONE / 0 Glucose (in mg/dl) / NONE / 0 Iron (in ug/dl) / NONE / 0 LDH (in IU/L) / NONE / 0 Lipase (in U/L) / NONE / 0 Magnesium (in mg/dl) / NONE / 1 Phosphorous (in mg/dl) / NONE / 1 Potassium (K+) (in mmol/l) / NONE / 1 Sodium (NA+) (in mmol/l) / NONE / 0 TIBC (in ug/dl) / NONE / 1 Total Protein (in g/dl) / NONE / 1 Triglycerides (in mg/dl) / NONE / 0 Triiodothyronine (T3) (in ng/ml) / NONE / 1 TSH (in uu/ml) / NONE / 2 Urea Nitrogen (BUN) (in mg/dl) / NONE / 0 Uric Acid (in mg/dl) / NONE / 1 MultiChem C / Active Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:2

3 Free T4 (in ng/dl) / NONE / 2 Albumin (in g/dl) / NONE / 1 Alkaline Phosphatase (in IU/L) / NONE / 0 ALT/SGPT (in IU/L) / NONE / 0 Amylase (in IU/L) / NONE / 0 AST/SGOT (in IU/L) / NONE / 0 Bilirubin Direct (in mg/dl) / NONE / 2 Bilirubin Total (in mg/dl) / NONE / 1 Calcium (in mg/dl) / NONE / 1 Chloride (CL-) (in mmol/l) / NONE / 0 Cholesterol HDL (in mg/dl) / NONE / 0 Cholesterol LDL (in mg/dl) / NONE / 0 Cholesterol Total (in mg/dl) / NONE / 0 CO2 (Total CO2 Bicarb) (in mmol/l) / NONE / 0 Creatine Kinase (in IU/L) / NONE / 0 Creatinine (in mg/dl) / NONE / 2 GGT (in IU/L) / NONE / 0 Glucose (in mg/dl) / NONE / 0 Iron (in ug/dl) / NONE / 0 LDH (in IU/L) / NONE / 0 Lipase (in U/L) / NONE / 0 Magnesium (in mg/dl) / NONE / 1 Phosphorous (in mg/dl) / NONE / 1 Potassium (K+) (in mmol/l) / NONE / 1 Sodium (NA+) (in mmol/l) / NONE / 0 TIBC (in ug/dl) / NONE / 1 Total Protein (in g/dl) / NONE / 1 Triglycerides (in mg/dl) / NONE / 0 Triiodothyronine (T3) (in ng/ml) / NONE / 1 TSH (in uu/ml) / NONE / 2 Urea Nitrogen (BUN) (in mg/dl) / NONE / 0 Uric Acid (in mg/dl) / NONE / 1 Complete Urinalysis Package 2019 A / Active Microscopy Urine Sed ABC Urine Sediment Id Quidel QuickVue One-Step Urine ABC Urine hcg Siemens Clinitek 50 ABC Urine Bilirubin Urine Blood/Hemoglobin Urine Glucose (Reducing Sub) Urine Ketones Urine Leuk Esterase Urine Nitrite Urine ph Urine Protein - Qual Urine Sp Gravity Urine Urobilingen Complete Urinalysis Package 2019 B / Active Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:3

4 Microscopy Urine Sed ABC Urine Sediment Id Quidel QuickVue One-Step Urine ABC Urine hcg Siemens Clinitek 50 ABC Urine Bilirubin Urine Blood/Hemoglobin Urine Glucose (Reducing Sub) Urine Ketones Urine Leuk Esterase Urine Nitrite Urine ph Urine Protein - Qual Urine Sp Gravity Urine Urobilingen Complete Urinalysis Package 2019 C / Active Microscopy Urine Sed ABC Urine Sediment Id Quidel QuickVue One-Step Urine ABC Urine hcg Siemens Clinitek 50 ABC Urine Bilirubin Urine Blood/Hemoglobin Urine Glucose (Reducing Sub) Urine Ketones Urine Leuk Esterase Urine Nitrite Urine ph Urine Protein - Qual Urine Sp Gravity Urine Urobilingen Glycohemoglobin 2019 A / Active Beck Coulter UniCel DxC 600, 800 Synchron ABC Glycohemoglobin (in percent) / NONE / 1 Glycohemoglobin 2019 B / Active Beck Coulter UniCel DxC 600, 800 Synchron ABC Glycohemoglobin (in percent) / NONE / 1 Glycohemoglobin 2019 C / Active Beck Coulter UniCel DxC 600, 800 Synchron ABC Glycohemoglobin (in percent) / NONE / 1 Special Chemistry II 2019 A / Active Vitamin D (in ng/ml) / NONE / 2 Special Chemistry II 2019 B / Active Vitamin D (in ng/ml) / NONE / 2 Special Chemistry II 2019 C / Active Vitamin D (in ng/ml) / NONE / 2 Special Chemistry 2019 A / Active Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:4

5 Ferritin (in ng/ml) / NONE / 1 Folate (in ng/ml) / NONE / 1 PSA (in ng/ml) / NONE / 2 Testosterone (in ng/ml) / NONE / 1 Vitamin B12 (in pg/ml) / NONE / 0 Special Chemistry 2019 B / Active Ferritin (in ng/ml) / NONE / 1 Folate (in ng/ml) / NONE / 1 PSA (in ng/ml) / NONE / 2 Testosterone (in ng/ml) / NONE / 1 Vitamin B12 (in pg/ml) / NONE / 0 Special Chemistry 2019 C / Active Ferritin (in ng/ml) / NONE / 1 Folate (in ng/ml) / NONE / 1 PSA (in ng/ml) / NONE / 2 Testosterone (in ng/ml) / NONE / 1 Vitamin B12 (in pg/ml) / NONE / 0 Urine Microalbumin & Creatinine 2019 A / Active Urine Creatinine (in mg/dl) / NONE / 0 Urine Microalbumin (in mg/dl) / NONE / 0 Urine Microalbumin & Creatinine 2019 B / Active Urine Creatinine (in mg/dl) / NONE / 0 Urine Microalbumin (in mg/dl) / NONE / 0 Urine Microalbumin & Creatinine 2019 C / Active Urine Creatinine (in mg/dl) / NONE / 0 Urine Microalbumin (in mg/dl) / NONE / 0 Sed Rate (ESR) 2019 A / Active Modified Westergren - Plastic ABC Sedimentation Rate (in mm/hr) / NONE / 0 Sed Rate (ESR) 2019 B / Active Modified Westergren - Plastic ABC Sedimentation Rate (in mm/hr) / NONE / 0 Sed Rate (ESR) 2019 C / Active Modified Westergren - Plastic ABC Sedimentation Rate (in mm/hr) / NONE / 0 Auto Diff 5 (Beckman Coulter 5-Part Diff) 2019 A / Active Beckman Coulter HmX ABC Basophil (in percent) / NONE / 2 Eosinophil (in percent) / NONE / 1 Hematocrit (in percent) / NONE / 1 Hemoglobin (in g/dl) / NONE / 1 Lymphocyte (in percent) / NONE / 1 MCV (in fl) / NONE / 1 Monocyte (in percent) / NONE / 2 Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:5

6 Neutrophil (in percent) / NONE / 1 Platelet Count (in 10^9/L) / NONE / 0 RDW (in percent) / NONE / 1 Red Blood Cell Count (in 10^12/L) / NONE / 2 White Blood Cell Count (in 10^9/L) / NONE / 1 Auto Diff 5 (Beckman Coulter 5-Part Diff) 2019 B / Active Beckman Coulter HmX ABC Basophil (in percent) / NONE / 2 Eosinophil (in percent) / NONE / 1 Hematocrit (in percent) / NONE / 1 Hemoglobin (in g/dl) / NONE / 1 Lymphocyte (in percent) / NONE / 1 MCV (in fl) / NONE / 1 Monocyte (in percent) / NONE / 2 Neutrophil (in percent) / NONE / 1 Platelet Count (in 10^9/L) / NONE / 0 RDW (in percent) / NONE / 1 Red Blood Cell Count (in 10^12/L) / NONE / 2 White Blood Cell Count (in 10^9/L) / NONE / 1 Auto Diff 5 (Beckman Coulter 5-Part Diff) 2019 C / Active Beckman Coulter HmX ABC Basophil (in percent) / NONE / 2 Eosinophil (in percent) / NONE / 1 Hematocrit (in percent) / NONE / 1 Hemoglobin (in g/dl) / NONE / 1 Lymphocyte (in percent) / NONE / 1 MCV (in fl) / NONE / 1 Monocyte (in percent) / NONE / 2 Neutrophil (in percent) / NONE / 1 Platelet Count (in 10^9/L) / NONE / 0 RDW (in percent) / NONE / 1 Red Blood Cell Count (in 10^12/L) / NONE / 2 White Blood Cell Count (in 10^9/L) / NONE / 1 Step 4: Keep this confirmation document with your laboratory records as proof of enrollment. Step 5: changes to AAFP-PT at pt@aafp.org. You will receive a new Enrollment Confirmation by within 7-10 days. Print Date & Time: 3/19/ :26:35 AM Part No.: CR Page:6