2015 SHIP DATES M1: Feb. 2 • M2: May 11 • M3: Sept. 14 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 “2015 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 2015 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 12, 2014, 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”). 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 a 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. 3. Print the name of the laboratory director. 22 www.acponline.org/mle Medical Laboratory Evaluation 2015 MLE Proficiency Testing Price List Code/Description *Full Year HEMATOLOGY 210/Hematology . . . . . . . . . . . . . . . . . . . . . . . . .$240 211/Basic Hematology . . . . . . . . . . . . . . . . . . . .$228 212/Hemoglobin/Hematocrit . . . . . . . . . . . . . . .$204 213/Hemoglobin/Hematocrit  . . . . . . . . . . . . .$147 215/Hemoglobin/Glucose—HemoCue . . . . . . . .$156 223/Abbott 5-Part Diff . . . . . . . . . . . . . . . . . . . .$330 224/Sysmex 3-Part Diff . . . . . . . . . . . . . . . . . . .$261 225/Hematology 3-Part Diff . . . . . . . . . . . . . . . .$282 226/Hematology 5-Part Diff . . . . . . . . . . . . . . . .$330 228/Hematology 5-Part diffACT 5 & Pentra 60C+ . . . . . . . . . . . . . . . . . . .$330 229/Hematology 5-Part diff-Sysmex XE/XT . . . . . . . . . . . . . . . . . . . . .$330 230/Blood Cell Id  . . . . . . . . . . . . . . . . . . . . . . .$36 231/Blood Cell Id . . . . . . . . . . . . . . . . . . . . . . . .$108 240/Reticulocyte Count . . . . . . . . . . . . . . . . . . .$210 247/Sed Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . .$168 248/Sed Rate-Sedimat15 . . . . . . . . . . . . . . . . . .$168 250/Body Fluid/Cell Ct/Cryst . . . . . . . . . . . . . .$168 Code/Description *Full Year 648/Colony Count . . . . . . . . . . . . . . . . . . . . . . . .$207 649/Presump.ID/CC/Strep A Antigen . . . . . . . .$315 650/Gram Stain . . . . . . . . . . . . . . . . . . . . . . . . .$177 652/Throat Culture/Urine Presump ID . . . . . . . . . . . . . . . . . . . . . . . . . . .$333 654/Genital Culture  . . . . . . . . . . . . . . . . . . . $123 660/Strep A Antigen Detection . . . . . . . . . . . . .$174 662/Strep A Antigen  . . . . . . . . . . . . . . . . . . .$105 668/Affirm VP Antigen Testing . . . . . . . . . . . . .$399 320/Coagulation . . . . . . . . . . . . . . . . . . . . . . . . .$189 321/Prothrombin Time . . . . . . . . . . . . . . . . . . . .$180 324/Roche CoaguChek XS INR  . . . . . . . . . .$165 328/i-STAT Pro Time . . . . . . . . . . . . . . . . . . . . .$333 330/CoaguChek XS PLUS Pro Time . . . . . . . . .$285 331/CoaguChek XS PLUS Pro Time  . . . . . .$165 BLOOD BANK 450/Rh Factor (D Type) . . . . . . . . . . . . . . . . . . .$237 451/ABO & Rh Factor (D Type) . . . . . . . . . . . . .$276 452/Blood Bank I . . . . . . . . . . . . . . . . . . . . . . . .$378 453/Blood Bank II . . . . . . . . . . . . . . . . . . . . . . .$396 URINALYSIS 530/Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . .$105 531/Urinalysis Dipstick . . . . . . . . . . . . . . . . . . . .$84 532/Urine Sed Id . . . . . . . . . . . . . . . . . . . . . . . .$108 533/Urine Sed Id  . . . . . . . . . . . . . . . . . . . . . . .$27 534/PPM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$114 535/PPM  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$33 536/Microalbumin/Creatinine—Quant  . . . . .$87 537/Fecal Occult Blood  . . . . . . . . . . . . . . . . . .$81 538/KOH Slides . . . . . . . . . . . . . . . . . . . . . . . . .$153 539/Microalbumin/Creatinine—Quant . . . . . . .$108 540/Urine hCG  . . . . . . . . . . . . . . . . . . . . . . . .$27 541/Urine hCG . . . . . . . . . . . . . . . . . . . . . . . . . . .$78 542/Fecal Occult Blood . . . . . . . . . . . . . . . . . . . .$105 MICROBIOLOGY 630/Bacteriology 1 . . . . . . . . . . . . . . . . . . . . . . .$306 640/Bacteriology 2 . . . . . . . . . . . . . . . . . . . . . . .$294 641/Throat Culture . . . . . . . . . . . . . . . . . . . . . .$282 642/Throat Culture/Strep A Antigen . . . . . . . . .$273 643/Urine Culture . . . . . . . . . . . . . . . . . . . . . . .$282 644/Urine Culture/Strep Antigen . . . . . . . . . . .$273 645/Urine/Throat Culture . . . . . . . . . . . . . . . . .$288 646/Genital Culture . . . . . . . . . . . . . . . . . . . . . .$282 647/Urine Culture/Presump.ID/CC . . . . . . . . . .$333 *Full Year CHEMISTRY 810/Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . .$342 811/Cholestech Chemistry  . . . . . . . . . . . . . .$168 812/Piccolo Waived Chemistry . . . . . . . . . . . . . .$210 813/Comp. Metabolic Panel . . . . . . . . . . . . . . . .$276 814/Basic Metabolic Panel . . . . . . . . . . . . . . . . .$216 815/Hepatic Profile . . . . . . . . . . . . . . . . . . . . . . .$210 816/Hepatic Profile  . . . . . . . . . . . . . . . . . . . . .$45 817/i-STAT Chemistry 1 . . . . . . . . . . . . . . . . . .$336 670/Chlamydia (EIA, DNA) . . . . . . . . . . . . . . . .$327 818/i-STAT Chemistry 2 . . . . . . . . . . . . . . . . . .$237 819/Chemistry 1 . . . . . . . . . . . . . . . . . . . . . . . . .$192 673/Chlamydia  . . . . . . . . . . . . . . . . . . . . . . . .$144 820/Chemistry 2 . . . . . . . . . . . . . . . . . . . . . . . . .$228 675/Chlamydia/GC (EIA, DNA ) . . . . . . . . . . . .$354 821/Chemistry 3 . . . . . . . . . . . . . . . . . . . . . . . . .$258 678/Dermatophyte Screen . . . . . . . . . . . . . . . . .$189 822/Add’l Chemistry  . . . . . . . . . . . . . . . . . . . .$45 680/Resp. Antigen Det.  . . . . . . . . . . . . . . . . .$186 823/Enzyme Chemistry  . . . . . . . . . . . . . . . . . .$45 681/Resp. Antigen Detection . . . . . . . . . . . . . . .$285 682/C. diff/Rotavirus Ag Det. . . . . . . . . . . . . . . .$249 683/Giardia lamblia/ Cryptosporidium Ag Det . . . . . . . . . . . . . . . .$300 COAGULATION Code/Description 686/Legionella Antigen Detection . . . . . . . . . . .$225 687/Strep Pneumoniae Antigen Det. . . . . . . . . .$225 690/Parasitology . . . . . . . . . . . . . . . . . . . . . . . . .$276 695/MRSA Screen (5 challenges) . . . . . . . . . . . .$267 IMMUNOLOGY 740/Additional Specific Allergen Material . . . . .$78 750/Immunology Module . . . . . . . . . . . . . . . . .$264 751/Rheumatology Module . . . . . . . . . . . . . . . .$186 755/Infectious Mono  . . . . . . . . . . . . . . . . . . .$108 761/Infect Mono/Rheumatoid Factor . . . . . . . . .$246 762/Infectious Mono . . . . . . . . . . . . . . . . . . . . . .$183 824/Thyroid Profile . . . . . . . . . . . . . . . . . . . . . . .$237 825/Thyroid Profile  . . . . . . . . . . . . . . . . . . . . .$54 826/Lipid Profile . . . . . . . . . . . . . . . . . . . . . . . . .$228 827/Lipid Profile  . . . . . . . . . . . . . . . . . . . . . . .$45 829/Apolipoproteins . . . . . . . . . . . . . . . . . . . . . .$129 830/TDM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$225 831/TDM  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$60 832/i-STAT Chemistry  . . . . . . . . . . . . . . . . .$168 834/Additional Chemistries . . . . . . . . . . . . . . .$216 835/Serum Alcohol/Acetone . . . . . . . . . . . . . . . .$225 836/Ammonia . . . . . . . . . . . . . . . . . . . . . . . . . . .$159 837/Blood Lead . . . . . . . . . . . . . . . . . . . . . . . . . .$336 838/Blood Lead  . . . . . . . . . . . . . . . . . . . . . . .$201 841/Neonatal Bilirubin . . . . . . . . . . . . . . . . . . .$219 842/Direct Bilirubin  . . . . . . . . . . . . . . . . . . . .$39 843/Direct Bilirubin . . . . . . . . . . . . . . . . . . . . . .$141 845/Cardiac Markers . . . . . . . . . . . . . . . . . . . . .$297 846/BNP/D-Dimer . . . . . . . . . . . . . . . . . . . . . . . $213 763/Rheumatoid Factor . . . . . . . . . . . . . . . . . . .$180 847/Blood Gases 764/CRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$108 850/Glycohemoglobin . . . . . . . . . . . . . . . . . . . . .$180 . . . . . . . . . . . . . . . . . . . . . . . .$288 765/HS-CRP . . . . . . . . . . . . . . . . . . . . . . . . . . . .$111 851/Afinion Glycohemoglobin . . . . . . . . . . . . . .$192 766/ANA LATEX . . . . . . . . . . . . . . . . . . . . . . . .$171 855/Fructosamine . . . . . . . . . . . . . . . . . . . . . . . .$153 767/ANA (ELISA/IMMUNO ONLY) . . . . . . . . .$183 859/PSA  770/Specific Allergen Testing . . . . . . . . . . . . . . .$336 860/Endocrinology/Hematology/Oncol . . . . . . . .$216 771/Rubella . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$177 861/PSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$126 772/Syphilis Serology . . . . . . . . . . . . . . . . . . . . .$198 862/Tumor Markers . . . . . . . . . . . . . . . . . . . . . .$381 863/Endocrinology 2 . . . . . . . . . . . . . . . . . . . . . .$186 864/Thyroid Antibodies . . . . . . . . . . . . . . . . . . .$228 865/Serum hCG . . . . . . . . . . . . . . . . . . . . . . . . .$171 866/Serum hCG  . . . . . . . . . . . . . . . . . . . . . . . .$87 868/Urine Drug Screening—Qual . . . . . . . . . . .$198 870/Whole Blood Glucose . . . . . . . . . . . . . . . . . .$255 871/Whole Blood Glucose  . . . . . . . . . . . . . . .$153 872/Urine Chemistry . . . . . . . . . . . . . . . . . . . . .$219 880/Add’l Chem Testing Material . . . . . . . . . . .$108 901/Waived and PPM Package . . . . . . . . . . . . .$249 902/Basic Waived and PPM Package . . . . . . . .$210 773/Diagnostic Allergy . . . . . . . . . . . . . . . . . . . .$336 774/Lyme Disease Serology . . . . . . . . . . . . . . . $216 775/Viral Markers . . . . . . . . . . . . . . . . . . . . . . .$450 776/CRP  NOT HIGH-SENSITIVITY . . . . . . . . . . . . . . .$57 777/HS-CRP  . . . . . . . . . . . . . . . . . . . . . . . . . . .$60 778/ANA  (LATEX ONLY) . . . . . . . . . . . . . . .$108 779/ANA  (ELISA/IMMUNO ONLY) . . . . . .$120 780/H. pylori Antibody Det . . . . . . . . . . . . . . . .$153 781/Mycoplasma Antibody . . . . . . . . . . . . . . . . .$135 782/ANA Expanded . . . . . . . . . . . . . . . . . . . . . .$240 783/ANA Expanded  . . . . . . . . . . . . . . . . . . . .$180 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$57 SUPPLIES & SERVICES 100/Annual Fee (Includes Binder) . . . . . . . . . . . .$85 784/Comp/Immuno . . . . . . . . . . . . . . . . . . . . . . .$213 107/Hard copy of Participant Summary . . . . . . .$51 789/diagnostics direct Syphilis Health Check .$210 121/1mL Pipette . . . . . . . . . . . . . . . . . . . . . . . . . .$25 790/Anti-HIV  . . . . . . . . . . . . . . . . . . . . . . . . .$159 791/Anti-HIV . . . . . . . . . . . . . . . . . . . . . . . . . . .$312 126/Pipette Pump . . . . . . . . . . . . . . . . . . . . . . . . .$45 142/NIR Subscription . . . . . . . . . . . . . . . . . . . . .$160 =Waived • =Add-On • *Enroll after the 1st event and prices are prorated by 1/3 per event. Medical Laboratory Evaluation 2015 www.acponline.org/mle 23 2015 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. 2 Bill To: (please clearly print or type) Contact ________________________________________________ Contact ________________________________________________ Facility Name __________________________________________ Facility Name __________________________________________ Address ________________________________________________ _______________________________________________________ Address ________________________________________________ _______________________________________________________ City _____________________________State ____ZIP _________ City _________________________State________ZIP _________ Country (other than U.S.): _______________________________ 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 DISCOUNT OFFERS 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 ACP Member - 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. ______________________ Multisite - SAVE 10% on 5 or more labs Management Group Code ____________ Consultant - SAVE 10% on 5 or more labs Consultant Code_____________________ State/Federal Agencies - SAVE 15% (U.S.) One-Time Discounts NEW MLE & COLA Member - SAVE $85 CAP accredited - SAVE $85 First year with MLE ($500 mininum order) - SAVE $85 Medical Laboratory Evaluation 2015