Download american association of bioanalysts proficiency testing

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 # 1009053 Chemistry, Basic & Comprehensive
TESTING FOR TOTAL PSA (non-tumor marker), TESTOSTERONE - SELECT PROGRAM CATALOG # 1009113 Chemistry, Special
TESTING FOR VITAMIN D - SELECT PROGRAM CATALOG # 1009893 Immunochemistry www.qualigeninc.com AMERICAN ASSOCIATION OF BIOANALYSTS
PROFICIENCY TESTING SERVICE
Order
Form
20152016
ORDER
FORM
PAYMENT OPTIONS
205 West Levee Street
800.234.5315
Brownsville, Texas 78520281.436.5357
www.aab-pts.org E-mail: [email protected]
Fax 956.542.4041
Account No.
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Select the programs from the 2015 program
list, calculate total and select the appropriate
payment method from the below choices:
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[ ] Internal use only; a copy of my results is to be sent to my laboratory only. Note: state regulations may override this request.
o PURCHASE ORDER ENCLOSED.
[ ] CLIA regulations; a copy of my results is to be sent to CMS (formerly HCFA) and my State Agency. CLIA No.
[ ] COLA requirements; a copy of my results is to be sent to COLA and my State Agency. State No.
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Orders received with letters of authorization are subject
to terms of Net 30 from AAB’s receipt of order.
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09012015
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1
Proficiency Testing Service I AAB
11
Institution Name: ___________________________________________________________________________________
CLIA #:
_______________________________________________________
2016 Programs Order Form
2016 Programs Order Form
Cat #
Program Description
X Price
Total
Cat #
Program Description
X Price
Provider Performed Microscopy
Chemistry - continued
1009693 Clinical Microscopy
$32
1009033 Chemistry, Basic
$239
1011363 Provider Performed Microscopy
$88
1009043 Chemistry, Comprehensive
$255
Point of Care Waived Tests
1009053 Chemistry, Basic & Comprehensive TSH, Free T4, hCG
$382
A1009613
Lipids Add On to Chemistry B/C
$36
2009203 Activated Clotting Time, 2-vial
$220
A1009813
TIBC/UIBC Add On to Chemistry B/C
$31
1001155 Chemistry, i-STAT, Waived
$185
1009933 Chemistry, i-STAT, Non-Waived
$295
1011263 Chemistry, Waived
$108
1001155 Chemistry, i-STAT, Waived
$185
A1011303
Pregnancy, Urine, Waived Add On
$48
1009113 Chemistry, Special Total PSA (non-tumor marker), Testosterone
$180
1009143 Drug Screen, Urine
$225
1001183 Chemistry & Microscopy, Body Fluid
$275
1002073 Eosinophils, Urine
$62
1009753 Chemistry, Urine
$190
1002033 Fecal Lactoferrin
$144
A1009643
Microalbumin/Creatinine, Urine add on to U-Chem.
$44
2002167 Glucose & Hemoglobin, 2-vial
$136
1011263 Chemistry, Waived
$108
1009163 Glucose, WB, Basic, Single-Site
$80
A1011303
Pregnancy, Urine, Waived add on to Wvd-Chem
$48
1009093 Glycohemoglobin, 2-vial
$163
2009713 C-Reactive Protein, high sensitivity
$108
2009403 Helicobacter Pylori
$140
2009763 D-Dimer
$155
1011273 Hemoglobin & Hematocrit, Waived
$122
1009123 Drug Monitoring, Therapeutic
$210
1011283 HIV Markers, Rapid, Waived
$150
1009143 Drug Screen, Urine
$225
1009923 Lead, Blood, Waived
$210
1002033 Fecal Lactoferrin
$144
2001693 Mononucleosis, Infectious, 2-vial Waived Methods
$80
1009073 Fertility Endocrinology
$197
1009783 Occult Blood, Fecal
$113
1009083 Fructosamine
$127
1002164 Occult Blood, Gastric
$151
2002167 Glucose & Hemoglobin, Hemocue, 2-vial
$136
1011303 Pregnancy, Urine, Waived
$73
1009163 Glucose, WB, Basic, Single-Site
$80
2009953 Prothrombin Time, Coaguchek XS/XS Plus, Basic
$155
1009183 Glucose, WB, Comprehensive, Single-Site
$158
1011323 Strep Group A Antigen Screen, Waived
$93
1009093 Glycohemoglobin, 2-vial
$163
1002163 Urease, Rapid (Clo-Test)
$136
1001973 Glycohemoglobin, 5-vial
$299
1009133 Urinalysis
$70
1001103 Hemoglobin A1C, Afinion
$167
2002153 Viral Antigen Screen, Waived
$149
1009893 Immunochemistry
$170
Vitamin D
Chemistry
1009813 Iron Binding (TIBC/UIBC)
$127
1002160 Adulterated Urine
$167
1009923 Lead, Blood, Waived
$210
1009013 Alcohol
$295
1009613 Lipids
$129
1009743 Ammonia, Blood
$135
1009643 Microalbumin/Creatinine, Urine
$75
1009633 Bilirubin, Direct/Neonatal, 2-vial
$101
1009783 Occult Blood, Fecal
$113
1002161 Bilirubin, Direct/Neonatal, 5-vial
$191
1002164 Occult Blood, Gastric
$151
1009023 Blood Gases (2 sets)
$382
1001113 Oximetry, Blood
$316
1011343 Cardiac Markers, 2-vial
$198
1009153 Pregnancy, Serum or Urine
$148
1009103 Cardiac Markers, 5-vial
$252
1011303 Pregnancy, Urine, Waived
$73
2009713F
C-Reactive Protein, high sensitivity (form only)
$62
1002293 SHBG & Testosterone
$405
1009883 Tumor Markers
$242
1009133 Urinalysis
$70
COLUMN 1
Subtotal
COLUMN 2
Subtotal
09012015
2
Total
Institution Name: ___________________________________________________________________________________
CLIA #:
________________________________________________________
2016 Programs Order Form
2016 Programs Order Form
Cat #
Program Description
X Price
Total
Cat #
Program Description
Hematology
Coagulation
1001156 Advanced Hematology with Manual Differentials
$108
2009203 Activated Clotting Time, 2-vial
2091003 Basic Hematology with Manual Differentials (PBS)
$108
2009213 Coagulation, Plasma
2009903 Blood Cell Identification
$46
2009953 Prothrombin Time, Coaguchek XS/XS Plus, Basic
1002073 Eosinophils, Urine
$62
2009963 Prothrombin Time, Coaguchek XS/XS Plus, Comp.
2009603 ESR
$131
2009223 Prothrombin Time, Whole Blood
2009863 ESR Rapid
$131
Immunohematology
2009283 Hematology, Centrifugal
$278
1001157 D (Rh) Typing
1011273 Hemoglobin and Hematocrit, Waived
$122
2009873 Direct Antiglobulin Test (DAT)
1041953 Hemoglobin and Hematocrit, 5-vial
$244
2001663 Fetal RBC
2009303 Hematology, w/Diff A
$250
2009353 Immunohematology, Basic
2009313 Hematology, w/Diff B
$305
2009363 Immunohematology, Comprehensive
2009323 Hematology, w/Diff C
$305
2002123 Immunohematology, Comprehensive Plus
2009333 Hematology, w/Diff D
$250
2009343 Hematology, w/Diff E
$305
Microbiology
2009793 Hematology, w/Diff G
$305
2009495 Acid-Fast Smears (2 events per year)
2009683 Reticulocyte Count, Automated & Manual
$225
2009803 Affirm Microbial Screen
1011333 Sickle Cell Screen
$156
2009503 Bacteriology
1011393 Bacteriology, Complete
Immunology
2001703 Blood Culture, add on
2009373 Anti-nuclear Antibody
$160
2009723 C. Difficile Antigen, 5-vial
2009383 Anti-streptolysin O
$134
2009513 Chlamydia/GC/Strep B
2009393 C-Reactive Protein
$90
2009673 Cryptosporidium/Giardia, 5-vial
2002313 Diagnostic Immunology
$386
2009523 Genital Culture, 5-vial
2009403 Helicobacter Pylori
$140
2009543 Gram Stain, 5-well slide
2009623 Hepatitis Markers
$208
112483 Gram Stain, supplemental
2009443 HIV Antibodies, 5-vial, Oral Fluid
$318
2001723 MRSA/VRE
1011283 HIV Markers, Rapid, Waived
$150
2009553 Parasitology
2009483 HIV Markers
$208
112493 Sensitivity, supplemental
2009413 Immunoproteins
$202
1011323 Strep Group A Antigen Screen, Waived
2009433 Lyme Disease
$176
2009563 Strep Group A Antigen Screen
2001693 Mononucleosis, Infectious, 2-vial Waived Methods
$80
2001753 Strep pneumoniae Antigen, add on
2009423 Mononucleosis, Infectious
$134
2001743 Shiga Toxin
2002173 Mycoplasma Antibody
$176
2009573 Throat Culture
2009453 Rheumatoid Factor
$134
2009583 Throat/Urine Culture w/Colony Count
A2002173 Rotavirus, 2-vial add on to any 5-vial culture
$165
1002163 Urease, Rapid (Clo-Test)
2002163 Rotavirus, 5-vial
$288
2091063 Urine Colony Count
2009463 Rubella
$150
2009593 Urine Culture w/Colony Count
2009473 Syphilis Serology
$170
2002153 Viral Antigen Screen, 2-vial Waived
1011355 ToRCH (2 testing events per year)
$220
2009733 Viral Antigen Screen
COLUMN 3
Subtotal
COLUMN 4
09012015
3
X
Price
$220
$155
$155
$245
$258
$133
$183
$273
$218
$330
$381
$174
$360
$285
$299
$172
$280
$379
$146
$240
$158
$98
$208
$250
$90
$93
$175
$127
$196
$290
$290
$136
$175
$265
$149
$319
Subtotal
Total
Institution Name: ___________________________________________________________________________________
CLIA #:
________________________________________________________
2016 Programs Order Form
2016 Programs Order Form
Cat #
Program Description
X Price
Total
Cat #
Program Description
qty Price
Mycology
Specialty Programs-continued
2001623 KOH Preparation
$172
Instrument Comparison
qty
40023 Blood Gases - Primary + 1 Secondary
$150
A40023 Blood Gases - each additional Secondary
$55
40103 Cardiac Markers - Primary + 1 Secondary
$250
A40103 Cardiac Markers - each additional Secondary
$175
41343 Cardiac Markers, 2 vial - Primary + 1 Secondary
$150
Andrology, Embryology & Fetal Tests
A41343 Cardiac Markers, 2 vial - each additional Secondary
$125
3009234 Antisperm Antibodies
$250
40053 Chemistry, Basic/Comp - Primary + 1 Secondary
$169
3009974 Embryo Grading
$245
A40053 Chemistry, Basic/Comp - each additional Secondary
$65
3009654 Fetal Fibronectin (fFN)
$328
40933 Chemistry, i-STAT, Non-Waived - Primary + 1 Secondary
$145
3001164 Fetal Membrane Rupture
$302
A40933 Chemistry, i-STAT, Non-Waived - each addn'l Secondary
$50
1001244 IVF Embryology Culture Media
$380
41553 Chemistry, i-STAT, Waived -Primary + 1 Secondary
$100
3009254 Sperm Count, for Quant & Qual (Post-vasectomy)
$250
A41553 Chemistry, i-STAT, Waived -each additional Secondary
$45
3009264 Sperm Morphology
$250
40123 Drug Monitoring, Therapeutic - Primary + 1 Secondary
$170
3009984 Sperm Motility
$245
A40123 Drug Monitoring, Therapeutic - each addn'l Secondary
$65
3009274 Sperm Viability
$250
41113 Oximetry, Blood - Primary + 1 Secondary
$156
A41113 Oximetry, Blood - each additional Secondary
$75
40203 Activated Clotting Time, 2-vial - Primary + 1 Secondary
$165
A40203 Activated Clotting Time, 2-vial - each addn'l Secondary
$125
40303 Hematolgy w/ Diff A - Primary + 1 Secondary
$240
40313 Hematolgy w/ Diff B - Primary + 1 Secondary
$281
40323 Hematolgy w/ Diff C - Primary + 1 Secondary
$281
Specialty Programs
40333 Hematolgy w/ Diff D - Primary + 1 Secondary
$240
2001583 Circulating Tumor Cell (CTC)
$300
40343 Hematolgy w/ Diff E - Primary + 1 Secondary
$281
1002453 eGFR (3 events per year)
$417
40793 Hematolgy w/ Diff G - Primary + 1 Secondary
$281
1002463 Cholesterol Certification (2 events per year)
$798
1009173 Glucose, WB, Basic, EQAS (Multisite)
$139
COLUMN 6 (above)
Subtotal
COLUMN 5
Subtotal
COLUMN 4
Subtotal
COLUMN 3
Subtotal
COLUMN 5
Subtotal
COLUMN 2
Subtotal
COLUMN 1
Subtotal
Total Program Order
INTERNATIONAL LABS
Annual Registration Fee (must accompany all orders)
***Call 800-234-5315 option 1 or email [email protected] 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.
09012015
4
Total
$75