How To Order

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