AMERICAN ASSOCIATION OF BIOANALYSTS PROFICIENCY TESTING SERVICE APPLICATION

Transcription

1 AMERICAN ASSOCIATION OF BIOANALYSTS PROFICIENCY TESTING SERVICE APPLICATION INSTRUCTIONS FOR USERS OF THE FASTPACK IP SYSTEM SELECT THE FOLLOWING PROGRAM CATALOG NUMBERS BASED ON THE TEST TYPES RUN: TESTING FOR TSH, FREE T4 AND hcg - SELECT PROGRAM CATALOG # Chemistry, Basic & Comprehensive TESTING FOR TOTAL PSA (non-tumor marker), TESTOSTERONE - SELECT PROGRAM CATALOG # Chemistry, Special TESTING FOR VITAMIN D - SELECT PROGRAM CATALOG # Immunochemistry

2 AMERICAN ASSOCIATION OF BIOANALYSTS PROFICIENCY TESTING SERVICE 2015 ORDER FORM 205 West Levee Street Brownsville, Texas Fax Account No. - XN FOR OFFICE USE ONLY SN-1 SN-2 SN-3 QN QC Order Date P.O. Date Purchase Order Amount Paid Amount to Bill PAYMENT options Select the programs from the 2015 program list, calculate total and select the appropriate payment method from the below choices: o CREDIT CARD. Fill out the information as indicated. SHIPPING ADDRESS (for delivery of testing material, physical street address is required). Name Institution Address PLEASE FILL OUT BELOW Card No. Exp Date. Authorized Amount: m m y y Security Code. o o o o Telephone - - Extension Telefax - - MAILING ADDRESS (for mail delivery of correspondence such as graded reports). Mail Address BILLING ADDRESS (for mail delivery of invoices and statements). Institution Mail Address Imprinting Desired on Certificate of Participation Indicate type of laboratory from listing on page XX of this brochure. ADDRESS Check below and, if applicable, enter number. Participation is for compliance with: [ ] Internal use only; a copy of my results is to be sent to my laboratory only. Note: state regulations may override this request. [ ] CLIA regulations; a copy of my results is to be sent to CMS (formerly HCFA) and my State Agency. CLIA No. D [ ] COLA requirements; a copy of my results is to be sent to COLA and my State Agency. State No. [ ] COLA requirements; a copy of my results is to be sent only to COLA. COLA No. [ ] CAP requirements; a copy of my results is to be sent to CAP. LAP No. (A copy of your certificate of accreditation from CAP is required for LAP number verification purposes.) Credit Card Billing Information (Fill out, if different from above). Card Holder s Name Card Holder s Company Name (if required) Card Holder s Bill-To Address Card Holder s City/State & Zip Card Holder s signature o PAYMENT ENCLOSED. Check or money order only. Make payable to : American Association of Bioanalysts TIN o PURCHASE ORDER ENCLOSED. Purchase order with terms of prepayment (advance payment) or Net 30 (from AAB s receipt of order). o LETTER OF AUTHORIZATION ENCLOSED. Orders received with letters of authorization are subject to terms of Net 30 from AAB s receipt of order. I desire Spanish literature. Signature Print Name and Title Phone: This order was placed by: ( ) - For questions regarding the surveys ordered, enter contact here: ( ) - For questions regarding payment/billing, enter contact here: ( ) Proficiency Testing Service I AAB 11

3 Institution Name: Cat # Program Description X Price Total Cat # Program Description X Price Total Provider Performed Microscopy Chemistry - continued Clinical Microscopy $ Chemistry, Basic $ Provider Performed Microscopy $ Chemistry, Comprehensive $255 Point of Care Waived Tests Chemistry, Basic & Comprehensive $382 A Lipids Add On to Chemistry B/C $ Activated Clotting Time, 2-vial $220 A TIBC/UIBC Add On to Chemistry B/C $ Chemistry, i-stat, Waived $ Chemistry, i-stat, Non-Waived $ Chemistry, Waived $ Chemistry, i-stat, Waived $185 A Pregnancy, Urine, Waived Add On $ Chemistry, Special $ Drug Screen, Urine $ Chemistry & Microscopy, Body Fluid $ Eosinophils, Urine $ Chemistry, Urine $ Fecal Lactoferrin $144 A Microalbumin/Creatinine, Urine add on to U-Chem. $ Glucose & Hemoglobin, 2-vial $ Chemistry, Waived $ Glucose, WB, Basic, Single-Site $80 A Pregnancy, Urine, Waived add on to Wvd-Chem $ Glycohemoglobin, 2-vial $ C-Reactive Protein, high sensitivity $ Helicobacter Pylori $ D-Dimer $ Hemoglobin & Hematocrit, Waived $ Drug Monitoring, Therapeutic $ HIV Markers, Rapid, Waived $ Drug Screen, Urine $ Lead, Blood, Waived $ Fecal Lactoferrin $ Mononucleosis, Infectious, 2-vial Waived Methods $ Fertility Endocrinology $ Occult Blood, Fecal $ Fructosamine $ Occult Blood, Gastric $ Glucose & Hemoglobin, Hemocue, 2-vial $ Pregnancy, Urine, Waived $ Glucose, WB, Basic, Single-Site $ Prothrombin Time, Coaguchek XS/XS Plus, Basic $ Glucose, WB, Comprehensive, Single-Site $ Strep Group A Antigen Screen, Waived $ Glycohemoglobin, 2-vial $ Urease, Rapid (Clo-Test) $ Glycohemoglobin, 5-vial $ Urinalysis $ Hemoglobin A1C, Afinion $ Viral Antigen Screen, Waived $ Immunochemistry $170 Chemistry Iron Binding (TIBC/UIBC) $ Adulterated Urine $ Lead, Blood, Waived $ Alcohol $ Lipids $ Ammonia, Blood $ Microalbumin/Creatinine, Urine $ Bilirubin, Direct/Neonatal, 2-vial $ Occult Blood, Fecal $ Bilirubin, Direct/Neonatal, 5-vial $ Occult Blood, Gastric $ Blood Gases (2 sets) $ Oximetry, Blood $ Cardiac Markers, 2-vial $ Pregnancy, Serum or Urine $ Cardiac Markers, 5-vial $ Pregnancy, Urine, Waived $ F C-Reactive Protein, high sensitivity (form only) $ SHBG & Testosterone $ Tumor Markers $ Urinalysis $70 COLUMN 1 COLUMN

4 Institution Name: Cat # Program Description X Price Total Cat # Program Description X Price Total Hematology Coagulation Advanced Hematology with Manual Differentials $ Activated Clotting Time, 2-vial $ Basic Hematology with Manual Differentials (PBS) $ Coagulation, Plasma $ Blood Cell Identification $ Prothrombin Time, Coaguchek XS/XS Plus, Basic $ Eosinophils, Urine $ Prothrombin Time, Coaguchek XS/XS Plus, Comp. $ ESR $ Prothrombin Time, Whole Blood $ ESR Rapid $131 Immunohematology Hematology, Centrifugal $ D (Rh) Typing $ Hemoglobin and Hematocrit, Waived $ Direct Antiglobulin Test (DAT) $ Hemoglobin and Hematocrit, 5-vial $ Fetal RBC $ Hematology, w/diff A $ Immunohematology, Basic $ Hematology, w/diff B $ Immunohematology, Comprehensive $ Hematology, w/diff C $ Immunohematology, Comprehensive Plus $ Hematology, w/diff D $ Hematology, w/diff E $305 Microbiology Hematology, w/diff G $ Acid-Fast Smears (2 events per year) $ Reticulocyte Count, Automated & Manual $ Affirm Microbial Screen $ Sickle Cell Screen $ Bacteriology $ Bacteriology, Complete $299 Immunology Blood Culture, add on $ Anti-nuclear Antibody $ C. Difficile Antigen, 5-vial $ Anti-streptolysin O $ Chlamydia/GC/Strep B $ C-Reactive Protein $ Cryptosporidium/Giardia, 5-vial $ Diagnostic Immunology $ Genital Culture, 5-vial $ Helicobacter Pylori $ Gram Stain, 5-well slide $ Hepatitis Markers $ Gram Stain, supplemental $ HIV Antibodies, 5-vial, Oral Fluid $ MRSA/VRE $ HIV Markers, Rapid, Waived $ Parasitology $ HIV Markers $ Sensitivity, supplemental $ Immunoproteins $ Strep Group A Antigen Screen, Waived $ Lyme Disease $ Strep Group A Antigen Screen $ Mononucleosis, Infectious, 2-vial Waived Methods $ Strep pneumoniae Antigen, add on $ Mononucleosis, Infectious $ Shiga Toxin $ Mycoplasma Antibody $ Throat Culture $ Rheumatoid Factor $ Throat/Urine Culture w/colony Count $290 A Rotavirus, 2-vial add on to any 5-vial culture $ Urease, Rapid (Clo-Test) $ Rotavirus, 5-vial $ Urine Colony Count $ Rubella $ Urine Culture w/colony Count $ Syphilis Serology $ Viral Antigen Screen, 2-vial Waived $ ToRCH (2 testing events per year) $ Viral Antigen Screen $319 COLUMN 3 COLUMN

5 Institution Name: Cat # Program Description X Price Total Cat # Program Description qty Price Total Mycology Specialty Programs-continued KOH Preparation $172 Instrument Comparison qty Blood Gases - Primary + 1 Secondary $150 A40023 Blood Gases - each additional Secondary $ Cardiac Markers - Primary + 1 Secondary $250 A40103 Cardiac Markers - each additional Secondary $ Cardiac Markers, 2 vial - Primary + 1 Secondary $150 Andrology, Embryology & Fetal Tests A41343 Cardiac Markers, 2 vial - each additional Secondary $ Antisperm Antibodies $ Chemistry, Basic/Comp - Primary + 1 Secondary $ Embryo Grading $245 A40053 Chemistry, Basic/Comp - each additional Secondary $ Fetal Fibronectin (ffn) $ Chemistry, i-stat, Non-Waived - Primary + 1 Secondary $ Fetal Membrane Rupture $302 A40933 Chemistry, i-stat, Non-Waived - each addn'l Secondary $ IVF Embryology Culture Media $ Chemistry, i-stat, Waived -Primary + 1 Secondary $ Sperm Count, for Quant & Qual (Post-vasectomy) $250 A41553 Chemistry, i-stat, Waived -each additional Secondary $ Sperm Morphology $ Drug Monitoring, Therapeutic - Primary + 1 Secondary $ Sperm Motility $245 A40123 Drug Monitoring, Therapeutic - each addn'l Secondary $ Sperm Viability $ Oximetry, Blood - Primary + 1 Secondary $156 A41113 Oximetry, Blood - each additional Secondary $ Activated Clotting Time, 2-vial - Primary + 1 Secondary $165 A40203 Activated Clotting Time, 2-vial - each addn'l Secondary $ Hematolgy w/ Diff A - Primary + 1 Secondary $ Hematolgy w/ Diff B - Primary + 1 Secondary $ Hematolgy w/ Diff C - Primary + 1 Secondary $281 Specialty Programs Hematolgy w/ Diff D - Primary + 1 Secondary $ Circulating Tumor Cell (CTC) $ Hematolgy w/ Diff E - Primary + 1 Secondary $ egfr (3 events per year) $ Hematolgy w/ Diff G - Primary + 1 Secondary $ Cholesterol Certification (2 events per year) $ Glucose, WB, Basic, EQAS (Multisite) $139 COLUMN 6 (above) COLUMN 5 COLUMN 4 COLUMN 3 COLUMN 5 COLUMN 2 COLUMN 1 Total Program Order INTERNATIONAL LABS Annual Registration Fee (must accompany all orders) $75 ***Call option 1 or customerservice@aab-pts.org for International Labs Shipping Surcharge*** (if applicable) the FedEx international shipping surcharge specific to your country. Total Payment Due Also includes Alaska, Hawaii, Puerto Rico, Guam & US Virgin Islands