2014 SHIP DATES M1: Feb. 3 • M2: May 12 • M3: Sept. 8 How To Order 4. Enter the laboratory’s CLIA identification number. If you do not know your CLIA identification number, contact your CMS Regional Office. If you would like assistance with designing the most economical order or have questions about our service or your order, contact MLE for assistance at 1-800-338-2746, option 5, or send us an e-mail at [email protected]. 5. Print the address of the location where the proficiency testing specimens and program paperwork should be shipped (if different from the “BILL TO” address). We will send the PT specimens via one-day express delivery to the “SHIP TO” address. For this reason, we cannot deliver specimens to a PO Box, so please provide a complete street address. Order Online with Ease! www.acponline.org/mle • Click on the “Enrollment Information” link. • Click on the “2014 MLE PT Online Order Form” link. • Complete the electronic form. It will calculate pricing for you. Once you submit the form, it will provide you with a summary of your order to print for your records. That’s it! If you are ordering an educational resource, click on the Educational Resources link. Order by Fax 6. Designate the regulatory agency(ies) or lab consultant(s) to receive a copy of your PT results by checking the appropriate box. Don’t forget to include the COLA or state agency number assigned to you, if applicable, and the name, address, and phone number of any other persons who should receive a copy of your results. Indicate “Auto Renewal”. Indicate “Express Evaluation Reports”. 7. Indicate a module number, description and price. Method of Payment 8. Specify the method of payment by checking the corresponding box. Complete the MLE PT order form on page 24. Fax your completed order form to MLE: 202-835-0440. If using a PO, please fax a copy of it with the order form. Enroll now to ensure the availability of specimens for the 2014 program year. We will not bill you until November. Subsequent enrollments will be billed within 1 week after activation and are payable within 30 days. Order by Mail Invoice Option: FAX (202-835-0440) the order form or MAIL it to the Washington, DC, address listed on the form. Billing terms are normally net 30 days from the date of invoice. Complete the MLE PT order form according to these instructions and mail it to the address printed on the form. Note: Purchase Orders (PO) must be accompanied by a renewal form or order form. POs by themselves will not be accepted. PT Order Form Instructions Enroll in MLE by December 13, 2013, to ensure you receive shipments for the entire year. You may enroll any time after the first event at a prorated cost depending on the availability of specimens. Using the PT Order Form Formulate Your Order Review the catalog to determine the products which best meet your proficiency testing (PT) needs. Note any instructions that refer to specific regulatory requirements or instrument/method compatibility. Choose the product most appropriate for your testing needs. Please pay close attention to instrument compatibility notes when selecting modules. Top Section Complete the PT order form (last page of catalog). 1. Indicate whether you are new to the MLE program or renewing your enrollment. 2. Print the address of the location where the invoice statement should be mailed (“BILL TO”). 3. Print the name of the laboratory director. 22 www.acponline.org/mle Credit Card Option: FAX (202-835-0440) the order form or MAIL it to the Washington, DC, address listed on the form. Check VISA or MasterCard, indicate the card bearer’s name, card number, CVV2#, and signature and the expiration date. Check Option: MAIL the order form and check to the Philadelphia address listed on the form. Purchase Order (PO) Option: FAX (202-835-0440) the order form or MAIL the order form and a copy of the PO to the Washington, DC, address listed on the form. Billing terms are net 30 days from the date of invoice. Tax ID: 23-1520302 DUNS NO: 071625974 Amount Due/Discounts 9. Add the cost of all the items you checked to the annual administration fee of $85. Enter the total amount in the box. If you qualify for an MLE ADVANTAGE discount, please check the appropriate box and provide the appropriate information. Next Step • Photocopy the order form for your records. • Within two weeks, you should receive an “Order Verification” confirming receipt of this order. If you do not receive the order verification within two weeks, please contact us immediately. The MLE products you order may contain pathogenic material. By returning the order form, you assume all risk and responsibility in connection with the receipt, handling, storage, use, and disposal of the products. Medical Laboratory Evaluation 2014 MLE Proficiency Testing Price List Code/Description *Full Year Code/Description *Full Year Code/Description *Full Year HEMATOLOGY 646/Genital Culture . . . . . . . . . . . . . . . . . . . . . .$264 CHEMISTRY 210/Hematology . . . . . . . . . . . . . . . . . . . . . . . . .$228 211/Basic Hematology . . . . . . . . . . . . . . . . . . . .$216 212/Hemoglobin/Hematocrit . . . . . . . . . . . . . . .$192 213/Hemoglobin/Hematocrit  . . . . . . . . . . . . .$135 215/Hemoglobin/Glucose—HemoCue . . . . . . . .$150 223/Abbott 5-Part Diff . . . . . . . . . . . . . . . . . . . .$318 224/Sysmex 3-Part Diff . . . . . . . . . . . . . . . . . . .$243 225/Hematology 3-Part Diff . . . . . . . . . . . . . . . .$270 226/Hematology 5-Part Diff . . . . . . . . . . . . . . . .$318 227/QBC Hematology . . . . . . . . . . . . . . . . . . . . .$318 228/Hematology 5-Part diffACT 5 & Pentra 60C+ . . . . . . . . . . . . . . . . . . .$318 229/Hematology 5-Part diff-Sysmex XE/XT . . . . . . . . . . . . . . . . . . . . .$318 230/Blood Cell Id  . . . . . . . . . . . . . . . . . . . . . . .$33 231/Blood Cell Id . . . . . . . . . . . . . . . . . . . . . . . .$102 240/Reticulocyte Count . . . . . . . . . . . . . . . . . . .$204 247/Sed Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . .$159 248/Sed Rate-Sedimat15 . . . . . . . . . . . . . . . . . .$159 250/Body Fluid/Cell Ct/Cryst . . . . . . . . . . . . . .$156 647/Urine Culture/Presump.ID/CC . . . . . . . . . .$321 810/Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . .$336 648/Colony Count . . . . . . . . . . . . . . . . . . . . . . . .$195 811/Cholestech Chemistry  . . . . . . . . . . . . . .$162 812/Piccolo Waived Chemistry . . . . . . . . . . . . . .$204 813/Comp. Metabolic Panel . . . . . . . . . . . . . . . .$270 814/Basic Metabolic Panel . . . . . . . . . . . . . . . . .$210 815/Hepatic Profile . . . . . . . . . . . . . . . . . . . . . . .$204 816/Hepatic Profile  . . . . . . . . . . . . . . . . . . . . .$45 COAGULATION 320/Coagulation . . . . . . . . . . . . . . . . . . . . . . . . .$183 321/Prothrombin Time . . . . . . . . . . . . . . . . . . . .$174 324/Roche CoaguChek XS INR  . . . . . . . . . .$138 328/i-STAT Pro Time . . . . . . . . . . . . . . . . . . . . .$255 329/ITC Pro Time  . . . . . . . . . . . . . . . . . . . . .$147 330/CoaguChek XS PLUS Pro Time . . . . . . . . .$228 331/CoaguChek XS PLUS Pro Time  . . . . . .$138 BLOOD BANK 450/Rh Factor (D Type) . . . . . . . . . . . . . . . . . . .$237 451/ABO & Rh Factor (D Type) . . . . . . . . . . . . . .*** 452/Blood Bank I . . . . . . . . . . . . . . . . . . . . . . . . .*** 453/Blood Bank II . . . . . . . . . . . . . . . . . . . . . . . . .*** 649/Presump.ID/CC/Strep A Antigen . . . . . . . .$300 650/Gram Stain . . . . . . . . . . . . . . . . . . . . . . . . .$168 652/Throat Culture/Urine Presump ID . . . . . . . . . . . . . . . . . . . . . . . . . . .$321 654/Genital Culture  . . . . . . . . . . . . . . . . . . . $111 660/Strep A Antigen Detection . . . . . . . . . . . . .$165 817/i-STAT Chemistry 1 . . . . . . . . . . . . . . . . . .$330 662/Strep A Antigen  . . . . . . . . . . . . . . . . . . . .$99 818/i-STAT Chemistry 2 . . . . . . . . . . . . . . . . . .$231 819/Chemistry 1 . . . . . . . . . . . . . . . . . . . . . . . . .$186 668/Affirm VP Antigen Testing . . . . . . . . . . . . .$396 820/Chemistry 2 . . . . . . . . . . . . . . . . . . . . . . . . .$222 670/Chlamydia (EIA, DNA) . . . . . . . . . . . . . . . .$318 821/Chemistry 3 . . . . . . . . . . . . . . . . . . . . . . . . .$252 673/Chlamydia  . . . . . . . . . . . . . . . . . . . . . . . .$135 822/Add’l Chemistry  . . . . . . . . . . . . . . . . . . . .$45 675/Chlamydia/GC (EIA, DNA ) . . . . . . . . . . . .$345 823/Enzyme Chemistry  . . . . . . . . . . . . . . . . . .$45 678/Dermatophyte Screen . . . . . . . . . . . . . . . . .$180 824/Thyroid Profile . . . . . . . . . . . . . . . . . . . . . . .$231 680/Resp. Antigen Det.  . . . . . . . . . . . . . . . . .$177 825/Thyroid Profile  . . . . . . . . . . . . . . . . . . . . .$54 826/Lipid Profile . . . . . . . . . . . . . . . . . . . . . . . . .$222 827/Lipid Profile  . . . . . . . . . . . . . . . . . . . . . . .$45 829/Apolipoproteins . . . . . . . . . . . . . . . . . . . . . .$126 830/TDM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$222 831/TDM  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$60 681/Resp. Antigen Detection . . . . . . . . . . . . . . .$279 682/C. diff/Rotavirus Ag Det. . . . . . . . . . . . . . . .$240 683/Giardia lamblia/ Cryptosporidium Ag Det . . . . . . . . . . . . . . . .$294 686/Legionella Antigen Detection . . . . . . . . . . .$198 751/Rheumatology . . . . . . . . . . . . . . . . . . . . . . .$180 832/i-STAT Chemistry  . . . . . . . . . . . . . . . . .$162 834/Additional Chemistries . . . . . . . . . . . . . . .$210 835/Serum Alcohol/Acetone . . . . . . . . . . . . . . . .$222 836/Ammonia . . . . . . . . . . . . . . . . . . . . . . . . . . .$153 841/Neonatal Bilirubin . . . . . . . . . . . . . . . . . . .$213 842/Direct Bilirubin  . . . . . . . . . . . . . . . . . . . .$39 843/Direct Bilirubin . . . . . . . . . . . . . . . . . . . . . .$135 845/Cardiac Markers . . . . . . . . . . . . . . . . . . . . .$198 755/Infectious Mono  . . . . . . . . . . . . . . . . . . .$102 846/BNP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $195 687/Strep Pneumoniae Antigen Det. . . . . . . . . .$198 690/Parasitology . . . . . . . . . . . . . . . . . . . . . . . . .$252 695/MRSA Screen (5 challenges) . . . . . . . . . . . .$255 IMMUNOLOGY 750/Immunology . . . . . . . . . . . . . . . . . . . . . . . .$258 761/Infect Mono/Rheumatoid Factor . . . . . . . . .$240 762/Infectious Mono . . . . . . . . . . . . . . . . . . . . . .$177 763/Rheumatoid Factor . . . . . . . . . . . . . . . . . . .$174 764/CRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$102 847/Blood Gases . . . . . . . . . . . . . . . . . . . . . . . .$282 848/Biosite Triage Cardiac Panel . . . . . . . . . . .$378 850/Glycohemoglobin . . . . . . . . . . . . . . . . . . . . .$174 851/Afinion Glycohemoglobin . . . . . . . . . . . . . .$174 855/Fructosamine . . . . . . . . . . . . . . . . . . . . . . . .$147 URINALYSIS 765/HS-CRP . . . . . . . . . . . . . . . . . . . . . . . . . . . .$105 858/d-Dimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . $108 530/Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . .$102 531/Urinalysis Dipstick . . . . . . . . . . . . . . . . . . . .$81 532/Urine Sed Id . . . . . . . . . . . . . . . . . . . . . . . .$105 533/Urine Sed Id  . . . . . . . . . . . . . . . . . . . . . . .$27 534/PPM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$111 535/PPM  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$33 536/Microalbumin/Creatinine—Quant  . . . . .$84 537/Fecal Occult Blood  . . . . . . . . . . . . . . . . . .$78 538/KOH Slides . . . . . . . . . . . . . . . . . . . . . . . . .$147 539/Microalbumin/Creatinine—Quant . . . . . . .$105 540/Urine hCG  . . . . . . . . . . . . . . . . . . . . . . . .$27 541/Urine hCG . . . . . . . . . . . . . . . . . . . . . . . . . . .$72 542/Fecal Occult Blood . . . . . . . . . . . . . . . . . . . . .$99 766/ANA LATEX . . . . . . . . . . . . . . . . . . . . . . . .$162 859/PSA  767/ANA (ELISA/IMMUNO ONLY) . . . . . . . . .$174 770/Specific Allergen Testing . . . . . . . . . . . . . . .$336 860/Endocrinology/Hematology/ Oncol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$198 771/Rubella . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$171 861/PSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$114 MICROBIOLOGY 630/Bacteriology 1 . . . . . . . . . . . . . . . . . . . . . . .$288 640/Bacteriology 2 . . . . . . . . . . . . . . . . . . . . . . .$276 641/Throat Culture . . . . . . . . . . . . . . . . . . . . . .$264 642/Throat Culture/Strep A Antigen . . . . . . . . .$264 643/Urine Culture . . . . . . . . . . . . . . . . . . . . . . .$273 644/Urine Culture/Strep Antigen . . . . . . . . . . .$273 645/Urine/Throat Culture . . . . . . . . . . . . . . . . .$273 772/Syphilis Serology . . . . . . . . . . . . . . . . . . . . .$192 773/Diagnostic Allergy . . . . . . . . . . . . . . . . . . . .$336 774/Lyme Disease Serology . . . . . . . . . . . . . . . $216 775/Viral Markers . . . . . . . . . . . . . . . . . . . . . . .$511 776/CRP  NOT HIGH-SENSITIVITY . . . . . . . . . . . . . . .$54 777/HS-CRP  . . . . . . . . . . . . . . . . . . . . . . . . . . .$57 778/ANA  (LATEX ONLY) . . . . . . . . . . . . . . .$105 779/ANA  (ELISA/IMMUNO ONLY) . . . . . .$114 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$48 862/Tumor Markers . . . . . . . . . . . . . . . . . . . . . .$381 863/Endocrinology 2 . . . . . . . . . . . . . . . . . . . . . .$180 864/Thyroid Antibodies . . . . . . . . . . . . . . . . . . .$222 865/Serum hCG . . . . . . . . . . . . . . . . . . . . . . . . .$165 866/Serum hCG  . . . . . . . . . . . . . . . . . . . . . . . .$87 868/Urine Drug Screening—Qual . . . . . . . . . . .$195 870/Whole Blood Glucose . . . . . . . . . . . . . . . . . .$252 871/Whole Blood Glucose  . . . . . . . . . . . . . . .$147 880/Add’l Chem Testing Material . . . . . . . . . . .$108 780/H. pylori Antibody Det . . . . . . . . . . . . . . . .$150 901/Waived and PPM Package . . . . . . . . . . . . .$225 902/Basic Waived and PPM Package . . . . . . . .$192 781/Mycoplasma Antibody . . . . . . . . . . . . . . . . .$132 100/Annual Fee (Includes Binder) . . . . . . . . . . . .$85 782/ANA Expanded . . . . . . . . . . . . . . . . . . . . . .$234 783/ANA Expanded  . . . . . . . . . . . . . . . . . . . .$174 784/Comp/Immuno . . . . . . . . . . . . . . . . . . . . . . .$210 790/Anti-HIV  . . . . . . . . . . . . . . . . . . . . . . . . .$141 791/Anti-HIV . . . . . . . . . . . . . . . . . . . . . . . . . . .$309 LAB SUPPLIES 121/1mL Pipette . . . . . . . . . . . . . . . . . . . . . . . . . .$20 126/Pipette Pump . . . . . . . . . . . . . . . . . . . . . . . . .$40 142/NIR Subscription . . . . . . . . . . . . . . . . . . . . .$160 ***Contact MLE for pricing =Waived • =Add-On • *Enroll after the 1st event and prices are prorated by 1/3 per event. Medical Laboratory Evaluation 2014 www.acponline.org/mle 23 2014 MLE Proficiency Testing Order Form 1 New Enrollee Renewing Participant: MLE ID # _________________________ CTLG 5 Ship To: (no PO boxes for kit delivery) Same as “bill to” address. Contact ________________________________________________ 2 Bill To: (please clearly print or type) Contact ________________________________________________ Facility Name __________________________________________ Facility Name __________________________________________ Address ________________________________________________ _______________________________________________________ Address ________________________________________________ _______________________________________________________ City _________________________State________ZIP _________ Country (other than U.S.): _______________________________ City _____________________________State ____ZIP _________ Phone ______________________Fax _______________________ Country (other than U.S.)________________________________ E-mail: ________________________________________________ Phone ______________________Fax _______________________ Ship kit to different address (attach information) E-mail _________________________________________________ 6 Send a copy of my PT results to: 3 Lab Director ____________________________________ CMS State Agency ID # __________________________ CAP/LAP # _________________________________________ COLA ID #__________________________________________ TJC ID # ___________________________________________ Other (attach name, address and phone number) 4 CLIA ID # _______________________________________ Activate Auto Renewal at no charge. (see page 16 for details) 7 Module # Description Price Ext. Module # Description Price Ext. Please note: Cancel a module IN WRITING up to 4 weeks prior to the upcoming shipment to avoid being charged. The MLE products you have ordered may contain pathogenic material. By returning this order form, you assume all risk and responsibility in connection with the receipt, handling, storage, use, and disposal of the material. 8 Method of Payment (Tax ID # 23-1520302) (DUNS #: 071625974) Send Invoice Check (payable to ACP/MLE) U.S. funds drawn on U.S. bank disclosure Purchase Order # ______________________ Charge to: VISA MasterCard Card # ___________________________________ Exp. ____________CVV2 (# on back)_________ Name on Card ____________________________ Signature ________________________________ Billing Street Number_____________________ Billing Zip _______________________________ Mailing the Order Form/Renewal Form WITH check: AC003 American College of Physicians 190 N. Independence Mall West Philadelphia, PA 19106-1572 24 www.acponline.org/mle ADVANTAGE Discounts WITHOUT check: Medical Laboratory Evaluation Suite 700 25 Massachusetts Avenue, NW Washington, DC 20001-7401 (Offers cannot be combined--see full description on the following page) Ongoing Discounts 1—MLE + ACP Membership - SAVE $85 9 Amount Due Total Cost of Items Above = $ _______ – Applied Discount Amount Subtotal = $ _______ $ _______ + Annual Administration Fee 85 $ _______ + Non-Continental Shipping Fee $ _______ (if applicable) Total Amount Due = $ _______ FAX this form to: 202-835-0440 (call 1-800-338-2746, option 5, to confirm receipt of fax) ACP Member No. ______________________ 4—Multisite Organization - SAVE 10% Management Group Code ____________ 5—Consultant-SAVE 10% Consultant Code_____________________ 8—State/Fed Agencies - SAVE 15% (U.S.) One-Time Discounts 2—NEW MLE + COLA Member - SAVE $85 10—CAP accredited - SAVE $85 14—First year with MLE ($500 mininum order) - SAVE $85 Medical Laboratory Evaluation 2014