MLE Logo

2010 U.S. MLE Proficiency Testing Order Form

Part I

Note: Items marked with * are required

* Order Type: Renewal   New Order
MLE ID# (MLE ID is required for RENEWAL)
If renewing and you are recruiting a colleague through the "Recruit 1, Waive 2" Program, indicate their name and phone number here:

1. Contact person in case we have questions:
*Name
*Phone
E-mail

2. Bill To:
*Attn
*Physician Name
*Facility Name
*Address
*City
State
Zip
Country
(if outside the U.S.)
*Phone
Fax
Email

3. Lab Director:
*Director

4. CLIA ID #:
CLIA ID # D Pending

5. Ship To (no P.O. boxes):
Same as billing address:
*Attn
*Physician Name
*Facility Name
*Address
*City
State
Zip
Country
(if outside the U.S.)
*Phone
Fax
Email

6. Send a copy of my proficiency testing results to:
CMS
COLA - ID #
State Agency - ID #
Other (if checked, complete mailing information below)
Name
Company
Address
City
State
Zip
Email
Phone
Fax
The person listed above is a consultant

7. Select the products that you wish to order:
Important: Please review the ordering instructions.
 
Hematology Quantity Full year M2 and M3 M3 Don't order
Please review prior to selecting your Hematology Module .
210 Hematology Module $ 171.00 $ 114.00 $ 57.00
211 Basic Hematology $ 159.00 $ 106.00 $ 53.00
212 Hemoglobin/Hematocrit $ 138.00 $ 92.00 $ 46.00
213 Hemoglobin/Hematocrit - Waived $ 111.00 $ 74.00 $ 37.00
215 Hemoglobin/Glucose $ 126.00 $ 84.00 $ 42.00
223 Hematology w/ 5-part Diff $ 279.00 $ 186.00 $ 93.00
224 Sysmex 3-Part Diff $ 207.00 $ 138.00 $ 69.00
225 Hematology with 3-Part Diff $ 207.00 $ 138.00 $ 69.00
226 Hematology with 5-Part Diff $ 279.00 $ 186.00 $ 93.00
227 QBC Hematology $ 279.00 $ 186.00 $ 93.00
228 Hematology w/ 5-part diff $ 279.00 $ 186.00 $ 93.00
229 Sysmex with 5-Part Diff $ 279.00 $ 186.00 $ 93.00
230 Blood Cell Identification(add-on) $ 27.00 $ 18.00 $ 9.00
231 Blood Cell Identification $ 90.00 $ 60.00 $ 30.00
240 Reticulocyte Count $ 180.00 $ 120.00 $ 60.00
247 Sedimentation Rate $ 141.00 $ 94.00 $ 47.00
248 Sedimat 15 ESR $ 141.00 $ 94.00 $ 47.00
250 Fluid Cell Count/Crystals $ 138.00 $ 92.00 $ 46.00
 
Coagulation Quantity Full year M2 and M3 M3 Don't order
320 Coagulation Module $ 150.00 $ 100.00 $ 50.00
321 Prothrombin Time $ 141.00 $ 94.00 $ 47.00
325 CoaguChek S Prothrombin Time $ 189.00 $ 126.00 $ 63.00
327 CoaguChek S Prothrombin Time-Waived $ 126.00 $ 84.00 $ 42.00
328 i-Stat Prothrombin Time $ 216.00 $ 144.00 $ 72.00
329 ITC ProTime® System - Waived $ 126.00 $ 84.00 $ 42.00
330 CoaguChek XS Plus Prothrombin Time $ 189.00 $ 126.00 $ 63.00
 
Blood Bank Quantity Full year M2 and M3 M3 Don't order
451 ABO & Rh Factor (D Type) $ 267.00 $ 178.00 $ 89.00
452 Blood Bank 1 $ 531.00 $ 354.00 $ 177.00
453 Blood Bank 2 $ 549.00 $ 366.00 $ 183.00
 
Urinalysis Quantity Full year M2 and M3 M3 Don't order
530 Urinalysis Module $ 78.00 $ 52.00 $ 26.00
531 Urinalysis Dipstick $ 60.00 $ 40.00 $ 20.00
532 Urine Sed ID $ 87.00 $ 58.00 $ 29.00
533 Urine Sed ID - Add on $ 18.00 $ 12.00 $ 6.00
534 Provider-Performed Microscopy (PPM) $ 90.00 $ 60.00 $ 30.00
535 PPM - Add on $ 21.00 $ 14.00 $ 7.00
536 Microalbumin - Add on $ 72.00 $ 48.00 $ 24.00
537 Fecal Occult Bld - Add On $ 66.00 $ 44.00 $ 22.00
538 KOH Slides $ 114.00 $ 76.00 $ 38.00
539 Microalbumin $ 84.00 $ 56.00 $ 28.00
540 Urine hCG - Add on $ 18.00 $ 12.00 $ 6.00
541 Urine hCG $ 42.00 $ 28.00 $ 14.00
542 Fecal Occult Blood $ 75.00 $ 50.00 $ 25.00
550 AmniSure Fetal Membrane Rupture Test - NEW $ 243.00 $ 162.00 $ 81.00
 
Microbiology Quantity Full year M2 and M3 M3 Don't order
630 Bacteriology 1 $ 252.00 $ 168.00 $ 84.00
640 Bacteriology 2 $ 243.00 $ 162.00 $ 81.00
641 Throat Culture (TC) $ 240.00 $ 160.00 $ 80.00
642 TC/Strep A Antigen $ 240.00 $ 160.00 $ 80.00
643 Urine Culture (UC) $ 240.00 $ 160.00 $ 80.00
644 Urine Culture/Strep A Antigen $ 240.00 $ 160.00 $ 80.00
645 Urine/Throat Culture $ 240.00 $ 160.00 $ 80.00
646 GC Culture $ 240.00 $ 160.00 $ 80.00
647 Urine Presump ID/CC $ 279.00 $ 186.00 $ 93.00
648 Colony Count Only $ 180.00 $ 120.00 $ 60.00
649 Urine Pres ID/Strep A $ 267.00 $ 178.00 $ 89.00
650 Gram Stain $ 150.00 $ 100.00 $ 50.00
652 Urine Presump ID/TC $ 279.00 $ 186.00 $ 93.00
654 GC Culture - Add on $ 96.00 $ 64.00 $ 32.00
660 Strep A Antigen $ 141.00 $ 94.00 $ 47.00
662 Strep A Antigen - Waived $ 84.00 $ 56.00 $ 28.00
668 Affirm® III VP (DNA) $ 357.00 $ 238.00 $ 119.00
670 Chlamydia (EIA, DNA) $ 270.00 $ 180.00 $ 90.00
673 Chlamydia (EIA, DNA) - Add on $ 114.00 $ 76.00 $ 38.00
675 Chlamydia/GC (EIA, DNA ) $ 297.00 $ 198.00 $ 99.00
678 Dermatophyte Screen $ 153.00 $ 102.00 $ 51.00
680 Rapid Antigen Det I-Waived $ 156.00 $ 104.00 $ 52.00
681 Rapid Antigen Detection 1 $ 249.00 $ 166.00 $ 83.00
682 Rapid Antigen Detection 2 $ 219.00 $ 146.00 $ 73.00
683 Giardia lamblia/Cryptosporidium Ag Det $ 201.00 $ 134.00 $ 67.00
686 Legionella Antigen Detection $ 156.00 $ 104.00 $ 52.00
687 Streptococcus Pneumoniae Antigen Detection $ 156.00 $ 104.00 $ 52.00
690 Parasitology $ 201.00 $ 134.00 $ 67.00
695 MRSA Screening $ 237.00 $ 158.00 $ 79.00
 
Immunology Quantity Full year M2 and M3 M3 Don't order
750 Immunology Module $ 228.00 $ 152.00 $ 76.00
751 Rheumatology Module $ 156.00 $ 104.00 $ 52.00
755 Infectious Mono - Waived $ 87.00 $ 58.00 $ 29.00
756 Tear Lactoferrin $ 108.00 $ 72.00 $ 36.00
757 Tear IgE $ 135.00 $ 90.00 $ 45.00
761 Infect Mono/Rheumatoid Factor $ 213.00 $ 142.00 $ 71.00
762 Infectious Mononucleosis $ 150.00 $ 100.00 $ 50.00
763 Rheumatoid Factor $ 150.00 $ 100.00 $ 50.00
764 C-Reactive Protein (CRP) $ 87.00 $ 58.00 $ 29.00
765 HS-CRP $ 87.00 $ 58.00 $ 29.00
766 Antinuclear Antibody (ANA) for latex methods ONLY $ 144.00 $ 96.00 $ 48.00
767 Antinuclear Antibody (ANA) for ELISA and immunofluoescence methods ONLY $ 144.00 $ 96.00 $ 48.00
768 Complement C3 and C4 $ 171.00 $ 114.00 $ 57.00
769 Immunoglobulins $ 162.00 $ 108.00 $ 54.00
770 Specific Allergen Testing $ 315.00 $ 210.00 $ 105.00
771 Rubella $ 147.00 $ 98.00 $ 49.00
772 Syphilis Serology $ 162.00 $ 108.00 $ 54.00
773 Diagnostic Allergy $ 315.00 $ 210.00 $ 105.00
774 Lyme Disease Serology $ 198.00 $ 132.00 $ 66.00
775 Viral Markers $ 345.00 $ 230.00 $ 115.00
776 CRP-Add-on $ 45.00 $ 30.00 $ 15.00
777 HS-CRP Add-on $ 48.00 $ 32.00 $ 16.00
778 ANA Add-on(LATEX ONLY) $ 87.00 $ 58.00 $ 29.00
779 ANA Add-on-(ELISA/IMMUNO ONLY) $ 87.00 $ 58.00 $ 29.00
780 H. pylori Antibody $ 132.00 $ 88.00 $ 44.00
781 Mycoplasma $ 114.00 $ 76.00 $ 38.00
782 ANA Expanded $ 204.00 $ 136.00 $ 68.00
783 ANA Expanded-Add-On $ 147.00 $ 98.00 $ 49.00
790 Anti-HIV - waived - NEW $ 132.00 $ 88.00 $ 44.00
791 Anti-HIV - NEW $ 300.00 $ 200.00 $ 100.00
 
Chemistry Quantity Full year M2 and M3 M3 Don't order
810 Chemistry Module $ 294.00 $ 196.00 $ 98.00
811 Cholestech Waived Chemistry $ 144.00 $ 96.00 $ 48.00
812 Piccolo Waived Chemistry $ 180.00 $ 120.00 $ 60.00
813 Comp. Metabolic Panel $ 222.00 $ 148.00 $ 74.00
814 Basic Metabolic Panel $ 171.00 $ 114.00 $ 57.00
815 Hepatic Profile $ 192.00 $ 128.00 $ 64.00
816 Hepatic Profile - Add On $ 36.00 $ 24.00 $ 12.00
817 i-STAT Chemistry 1 $ 342.00 $ 228.00 $ 114.00
818 i-STAT Chemistry 2 $ 201.00 $ 134.00 $ 67.00
819 Chemistry 1 $ 168.00 $ 112.00 $ 56.00
820 Chemistry 2 $ 198.00 $ 132.00 $ 66.00
821 Chemistry 3 $ 228.00 $ 152.00 $ 76.00
822 Additional Chemistry $ 36.00 $ 24.00 $ 12.00
823 Enzyme Chemistry - Add-on $ 36.00 $ 24.00 $ 12.00
824 Thyroid Profile $ 204.00 $ 136.00 $ 68.00
825 Thyroid Profile - Add on $ 45.00 $ 30.00 $ 15.00
826 Lipid Profile $ 198.00 $ 132.00 $ 66.00
827 Lipid Profile - Add on $ 36.00 $ 24.00 $ 12.00
829 Apolipoproteins $ 108.00 $ 72.00 $ 36.00
830 Therapeutic Drug Monitoring $ 198.00 $ 132.00 $ 66.00
831 Therapeutic Drug - Add on $ 45.00 $ 30.00 $ 15.00
832 i-STAT Chemistry-Waived - NEW $ 138.00 $ 92.00 $ 46.00
835 Serum Alcohol/Acetone $ 201.00 $ 134.00 $ 67.00
836 Ammonia $ 135.00 $ 90.00 $ 45.00
841 Neonatal Bilirubin $ 195.00 $ 130.00 $ 65.00
842 Direct Bilirubin - Add on $ 30.00 $ 20.00 $ 10.00
843 Direct Bilirubin $ 84.00 $ 56.00 $ 28.00
845 Cardiac Markers $ 159.00 $ 106.00 $ 53.00
846 BNP/NT-pro BNP $ 180.00 $ 120.00 $ 60.00
847 Blood Gases $ 264.00 $ 176.00 $ 88.00
848 Biosite Triage SOB Panel $ 351.00 $ 234.00 $ 117.00
850 Glycohemoglobin $ 138.00 $ 92.00 $ 46.00
851 Afinion Glycohemoglobin $ 138.00 $ 92.00 $ 46.00
855 Fructosamine $ 135.00 $ 90.00 $ 45.00
856 Blood Oximetry - NEW $ 225.00 $ 150.00 $ 75.00
857 Blood Oximetry - add-on - NEW $ 90.00 $ 60.00 $ 30.00
859 PSA - Add On $ 36.00 $ 24.00 $ 12.00
860 Endo/Heme/Oncol $ 174.00 $ 116.00 $ 58.00
861 PSA $ 93.00 $ 62.00 $ 31.00
862 Tumor Markers $ 354.00 $ 236.00 $ 118.00
863 Endocrinology 2 $ 156.00 $ 104.00 $ 52.00
864 Thyroid Antibodies $ 195.00 $ 130.00 $ 65.00
865 Serum hCG $ 150.00 $ 100.00 $ 50.00
866 Serum hCG - Add on $ 75.00 $ 50.00 $ 25.00
868 Urine Drug Screen $ 168.00 $ 112.00 $ 56.00
870 Whole Blood Glucose $ 231.00 $ 154.00 $ 77.00
871 WB Glucose - Waived $ 132.00 $ 88.00 $ 44.00
880 Addtl Chem Material $ 93.00 $ 62.00 $ 31.00
901 Waived and PPM Package $ 186.00 $ 124.00 $ 62.00
 
Lab Supplies/Services Quantity Full year M2 and M3 M3 Don't order
121 1 ml Pipette $ 20.00 $ 20.00 $ 20.00
126 Pipette pump $ 24.00 $ 24.00 $ 24.00
107 Par Sum $ 15.00 $ 15.00 $ 15.00
8. MLE'S ADVANTAGE DISCOUNT OFFERS - See If You Qualify! Eligibility Requirements

Note: Offers CANNOT be combined. (Choose the offer that provides you the greatest discount)

ACP ID#: (required for ADVANTAGE Offers 1 and 3)

COLA ID (required for ADVANTAGE Offers #2 and 3. Enter COLA ID on Item 6.)

1. - MLE with ACP Membership - SAVE $75
2. - NEW MLE with COLA Membership - SAVE $75
3. - NEW COLA, MLE Enrolled with ACP Membership - SAVE $75 PLUS 10%
4. - Multi-Site Organization (at least 3 branches enrolled) - SAVE 10%
Management Group Code (If known):
5. - Consultant - SAVE 10%
(To receive this discount, please complete Number 7 on this form)
8. - U.S. federal agency - save 15%
9. - 'Recruit 1, Waive 2' Recruitment Program - SAVE $75
13. Former MLE Participant - SAVE $75
14. Never enrolled in MLE - SAVE $75!
Don't choose