2017 Request for Quote - CAP Users Fax:

Transcription

1 Department 9526, P.O. Box 30516, Lansing, MI Request for Quote - CAP Users Fax: Date: Contact: Institution Name: Address 1: Address 2: City: State: Zip: Phone: Send completed quote to the following address: Fax: Network Name: Lab Accrediting Agency: Lab Accrediting ID#: CLIA #: Check here if you would like your order shipped to each department in a separate box. Please follow the instructions below for completing this form: LIS: API Customer No. (If applicable): API Representative: Representative 1) Fill out the top portion of the form. 2) Using your CAP Surveys order confirmation or invoice, check off the tests you are performing. Only answer the questions specific for the analytes in the CAP code(s) you check off. 3) Where indicated, answer ALL of the questions regarding instruments and check the analytes tested. List primary instruments first. 4) If you are using any other PT provider, please fill out the appropriate form for that provider. 5) Give the completed form to your API Representative; or FAX to: ; or it to PriceEstimate@api-pt.com. For an accurate and timely turnaround, please answer questions where indicated. ABF1 Automated Body Fluid ABF2 Automated Body Fluid ABF3 Automated Body Fluid ABT Antibody Titer ABT1 Antibody Titer ABT2 Antibody Titer AFL Amniotic Fluid Leakage AHIV Rapid Anti-HIV Method Name (s): AHIVW Rapid Anti-HIV Method Name (s): AL2 Alcohol Alcohol reported: Yes No Acetone reported (from AL2): Quant Qual Are you testing Ethylene Gly, Isopropanol or Methanol: Yes No ANA ANA Latex method: Yes No APT Fetal Hemoglobin AQ Critical Care Aqueous Blood Gas Are you testing more than ph, pco2, and po2: Yes No AQ2 Critical Care Aqueous Blood Gas AQ3 Critical Care Aqueous Blood Gas AQ4 Critical Care Aqueous Blood Gas ASA Semen Analysis ASO ASO BCP Blood Cell Identification BCR Crystals BCS Blood Culture BFC Crystals BGS Bone and Growth IGF-1 or Osteocalcin Performed: Yes No BL Blood Lead Instrument Name (s): BNP B-Type Natriuretic Peptides BNP5 B-Type Natriuretic Peptides - 5 sample BP Blood Parasite BV Bacterial Vaginosis C1 General Chemistry Apolipoproteins Performed: Yes No C3 General Chemistry Apolipoproteins Performed: Yes No C3X General Chemistry Apolipoproteins Performed: Yes No How many instruments do you want to report? CAMP Campylobacter CCP Cyclic-Citrullinated Peptide Antibody CGDF Coagulation, Limited D-dimer reported: Quantitative Qualitative FDP Performed: Yes No CGE Coagulation, Extended CGEX Coagulation, Extended CGL Coagulation, Limited D-dimer reported: Quantitative Qualitative FDP Performed: Yes No CGS6 Coagulation Special Testing Series CMMP Clinical Microscopy Miscellaneous KOH Test Performed on: Skin/Hair/Nails Vaginal CMP Clinical Microscopy Urine Sediment Performed: Yes No Body Fluid Microscopy Performed: Yes No Osmolality Performed: Yes No CMP1 Clinical Microscopy Urine Sediment Performed: Yes No Body Fluid Microscopy Performed: Yes No CRP CRP Results reported: Quantitative Qualitative

2 CRT Cardiac Markers How many instruments would you like to report?: CRTI CS CT CT1 CT2 CT3 CT5 CYS Cardiac Markers Immunosuppressive Drugs Cystatin C CZ General Chemistry and Therapeutic Drugs Apolipoproteins Performed: Yes No CZ2 General Chemistry and Therapeutic Drugs Apolipoproteins Performed: Yes No CZ2X General Chemistry and Therapeutic Drugs Apolipoproteins Performed: Yes No CZX General Chemistry and Therapeutic Drugs Apolipoproteins Performed: Yes No D Bacteriology C. difficile Performed: Yes No D1 D2 D3 D4 Limited Bacteriology GC Performed: Yes No D5 D6 D7 D8 D9 DAI DAT DSC DY Gram Stain Rapid Strep A Antigen Detection Group B Strep Detection Rapid Strep A Antigen Detection, Waived Urine Drug Adulterant/Integrity Testing Direct Antiglobulin Testing Dipstick Confirmatory Ligand Assay, Special E Mycobacteriology Acid Fast Smear Performed: Yes No E1 Limited Mycobacteriology Acid Fast Smear Performed: Yes No EHE1 ELU EPO Expanded Virtual Peripheral Blood Smear Eluate Survey Erythropoietin ESR Instrument Name (s): ESR1 ESR2 ESR3 EXM Electronic Crossmatch F Mycology Cryptococcal Antigen Performed: Yes No F1 Yeast Cryptococcal Antigen Performed: Yes No F3 FF Candida Culture Fetal Fibronectin Glutaraldehyde Performed: Yes No NOTE!! If your lab is performing BCID AND Auto Diff, API will grade both, but CMS will only accept one result (see catalog page 12 for details). Please select the option you want reported to CMS: BCID or Auto Diff Antifungal Suscept. Performed: Yes No FH1 Hematology Automated Differentials FH Series FH1P Hematology Automated Differentials FH Series FH2 Hematology Automated Differentials FH Series FH2P Hematology Automated Differentials FH Series FH3 Hematology Automated Differentials FH Series FH3P Hematology Automated Differentials FH Series FH4 Hematology Automated Differentials FH Series FH4P Hematology Automated Differentials FH Series FH6 Hematology Automated Differentials FH Series FH6P Hematology Automated Differentials FH Series FH9 Hematology Automated Differentials FH Series FH9P Hematology Automated Differentials FH Series FH10 Hematology Automated Differentials FH Series FH10P Hematology Automated Differentials FH Series FL1 Flow Cytometry FL2 Flow Cytometry FL5 Flow Cytometry, Interpretation Only FLAC Fecal Lactoferrin FLD Body Fluid Chemistry CA 19-9 Performed: Yes No CEA Performed: Yes No FSER Fungal Serology

3 A FSM FT G Fungal Smear Fructosamine Syphilis Serology GH2 Hemoglobin A1c Instrument Name(s): GH5 Hemoglobin A1c - 5 sample Instrument Name(s): GOCB HBF HC2 HC3 HC6 HC6X HCC HCG Gastric Occult Blood Fetal Red Cell Detection Herpes Simplex Virus Chlamydia trachomatis C.trachomatis and N. gonorrhoeae C.trachomatis and N. gonorrhoeae Waived Combination HCG, Serum HE Basic Hematology Instrument Name(s): HEP HFC HIV HMS hscrp Basic Hematology Hemocytometer Fluid Count HIV Viral Load Homocysteine High-Sensitivity/Cardiac C-Reactive Protein IG Immunology, General IgE Performed: Yes No Kappa/Lambda Ratio Performed: Yes No IGX Immunology, General IgE Performed: Yes No Kappa/Lambda Ratio Performed: Yes No IL Immunology CRP Reported: Quantitative Qualitative IM IMW IND Infectious Mononucleosis Infectious Mononucleosis, Waived India Ink HCG Performed: Yes No Mononucleosis Performed: Yes No RF Performed: Yes No Rubella Performed: Yes No ING C-Peptide, Gastrin, Insulin, and PTH Assays Gastrin Performed: Yes No J Transfusion Medicine, Comprehensive Transfusion Medicine, Compatibility Testing Performed: Yes No NOTE: If doing auto and manual, which do you want as your Primary (P) or Secondary (S): (Mark P or S) Auto Manual J1 Transfusion Medicine, Limited JAT Transfusion Medicine, Comp Transfusion Med, Compatibility Testing Auto Performed: Yes No NOTE: If doing auto and manual, which do you want as your Primary (P) or Secondary (S): (Mark P or S) Auto Manual JE1 Transfusion Medicine Educational Challenges K Ligand Assay, General IgE Performed: Yes No CEA Performed: Yes No T4 or TSH Performed: Yes No Free PSA Performed: Yes No ANA - Latex method: Yes No ANA - Non-latex method: Yes No ASO Performed: Yes No AFP Performed: Yes No KET Ketones Results reported: Beta-Hydroxy Acetone Qual (from KET) Acetone Quant (from KET) LBAS Bacterial Antigen Detection LCW Limited Chemistry, Waived M CSF Chemistry and Oligoclonal Bands Electrophoresis Performed: Yes No MRS Methicillin-Resistant Staph. aureus Screen MRS5 Methicillin-Resistant Staph. aureus Screen NB Neonatal Bilirubin NB2 OCB Neonatal Bilirubin Occult Blood P Parasitology Giardia or Cryptosporidium Performed: Yes No P5 Parasitology Method: Immunoassy or Modified Acid Fast Stain (2 samples for crypto and giardia) PCARM PCARMX PCT PF PF1 Plasma Cardiac Markers Plasma Cardiac Markers Procalcitonin Platelet Function Platelet Function PIA Drug-Specific Platelet Aggregation Aspirin Assay Performed: Yes No PLA PV R RF RHCVW ROM1 Lipoprotein-Associated Phospholipase A2 Semen Analysis Trace Metals Rheumatoid Factor Anti-HCV, Rapid Methods Rupture of Fetal Membranes Testing llb/llla Performed: Yes No PRU Performed: Yes No RT Instrument Name(s): RT2 RT3 RT4 RUB RUR Rubella Rapid Urease

4 S2 Immunology, Special and H.pylori IgG Antibody Thyroid Antibodies Performed: Yes No Prealbumin/ S4 Immunology, Special and H.pylori IgG Antibody Thyroid Antibodies Performed: Yes No Prealbumin/ S5 Immunology, Special and H.pylori IgG Antibody Thyroid Antibodies Performed: Yes No Prealbumin/ SBAS Bacterial Antigen Detection SC Semen Analysis SC1 Semen Analysis SCM1 Special Clinical Microscopy SCM2 Special Clinical Microscopy SCO Serum Carryover SCS Sickle Cell Screening SDS Serum Drug Screen List tests performed: SE Diagnostic Allergy SM Semen Analysis SM1CD Sperm Motility, Morphology, and Viability SM2CD Sperm Motility, Morphology, and Viability SMCD Sperm Motility, Morphology, and Viability Count Performed: Yes No Motility Performed: Yes No SO Blood Oximetry SP Stool Pathogen Adenovirus Performed: Yes No C. difficile Performed: Yes No Rotavirus Performed: Yes No Shiga Toxin Performed: Yes No SPE Lipoprotein and Protein Electrophoresis Electrophoresis Performed: Yes No ST Shiga Toxin SV Sperm Viability SW1 Sweat Analysis Series SW2 Sweat Analysis Series SW3 Sweat Analysis Series SW4 Sweat Analysis Series TEG Thromboelastogram TM Tumor Markers ACTH Performed: Yes No CA72-4 Performed: Yes No Calcitonin Performed: Yes No TMO Ticks, Mites, and Other Arthropods TMX Tumor Markers ACTH Performed: Yes No CA72-4 Performed: Yes No Calcitonin Performed: Yes No TNT Cardiac Markers TTD Tick-Transmitted Diseases U Urine Chemistry, General Total Nitrogen Performed: Yes No UAA Automated Urinalysis UAA1 Automated Urinalysis UDC Forensic Urine Drug Testing, Confirmatory UDS Urine Drug Testing, Screening UDS6 Urine Drug Testing, Screening UMC Urine Albumin (Microalbumin)/Creatinine URC Crystals VITD OH-25, Vitamin D VM1 Viral Markers - Series 1 VM2 Viral Markers - Series 2 VM3 Viral Markers - Series 3 VM4 Viral Markers - Series 4 VM5 Viral Markers - Series 5 VM6 Viral Markers - Series 6 Are you using the Alere Determine or Other Method VPBS Virtual Peripheral Blood smear Platelet Estimate Performed: Yes No WBC Diff Performed: Yes No VR1 Virology Culture VR2 Virology Antigen Detection (DFA) VR3 Infectious Disease Serology VR3M Infectious Disease Serology VR4 Virology Antigen Detection (Non-IF) Rotavirus Performed: Yes No VRE Vancomycin-Resistant Enterococcus

5 VS VS1 VS2 WB2 WBDD WBG WID WP10 WP3 Vaginitis Screen Vaginitis Screen Vaginitis Screen, Virtual Gram Stain Whole Blood Glucose Whole Blood D-Dimer Whole Blood Glucose Worm Identification WP4 Instrument Name(s): WP6 Instrument Name(s): WP9 Y Ligand Assay, Special Androstenedione Performed: Yes No Growth Hormone Performed: Yes No 11-deoxycortisol Performed: Yes No 17-hydroxyprogesterone Performed: Yes No YY Ligand Assay, Special Androstenedione Performed: Yes No Growth Hormone Performed: Yes No 11-deoxycortisol Performed: Yes No 17-hydroxyprogesterone Performed: Yes No Z Therapeutic Drugs ZE Therapeutic Drug Monitoring, Extended ZT List other tests not shown above: Therapeutic Drug Monitoring, Special IGF-1 Performed: Yes No IGF-1 Performed: Yes No