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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. - Select the programs from the 2015 program list, calculate total and select the appropriate payment method from the below choices: FOR OFFICE USE ONLY XN o CREDIT CARD. SN-1 SN-2SN-3 QN QC Order Date P.O. Date Purchase Order Amount Paid PLEASE FILL OUT BELOW SHIPPING ADDRESS (for delivery of testing material, physical street address is required). Name Amount to Bill Fill out the information as indicated. Card No. Exp Date. m m y Authorized Amount: y Security Code. Institution Address o City/State/Zip- Credit Card Billing Information (Fill out, if different from above). Telephone ____________________________________________________ -- Extension Telefax -- Card Holder’s Company Name (if required) ____________________________________________________ Card Holder’s Bill-To Address BILLING ADDRESS (for mail delivery of invoices and statements). Institution ____________________________________________________ Card Holder’s City/State & Zip Mail Address ____________________________________________________ Card Holder’s signature City/State/ZipImprinting Desired on Certificate of Participation o PAYMENT ENCLOSED. Check or money order only. Indicate type of laboratory from listing on page XX of this brochure. EMAIL ADDRESS Email Make payable to : American Association of Bioanalysts TIN 94-6114214 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. 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. [ ] COLA requirements; a copy of my results is to be sent only to COLA. COLA No. Purchase order with terms of prepayment (advance payment) or Net 30 (from AAB’s receipt of order). D o LETTER OF AUTHORIZATION ENCLOSED. Orders received with letters of authorization are subject to terms of Net 30 from AAB’s receipt of order. LAP No. [ ] CAP requirements; a copy of my results is to be sent to CAP. o ____________________________________________________ City/State/Zip- o Card Holder’s Name MAILING ADDRESS (for mail delivery of correspondence such as graded reports). Mail Address o (A copy of your certificate of accreditation from CAP is required for LAP number verification purposes.) I desire Spanish literature. 09012015 Signature Print Name and Title This order was placed by: Phone: ( ) - For questions regarding the surveys ordered, enter contact here: ( ) - For questions regarding payment/billing, enter contact here: ( ) - 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