Order Form Back - API Paperless Proficiency Testing

1 Send orders and payments to: Department 9526, Box 30516, Lansing, MI 48909-8016 800-333-0958 Fax: NumberHCO #LAP/CAP #COLA #API # (if applicable)___ ___ D ___ ___ ___ ___ ___ ___ ___Shipping InformationBilling InformationShipping ContactBilling ContactInstitution NameInstitution NameDepartmentDepartmentStreet Address (products cannot be shipped to a Box)Mailing AddressAddress 2 Address 2 CityStateZipCityStateZipPhone/Fax:Phone/ Fax:Email:Email:Send copies of reports to: (a copy will also be sent to the address above)Send additional copies of reports to: (attach a list if more than two)AttentionAttentionInstitution Name and AddressInstitution Name and AddressCityStateZipCityStateZipPhone/Fax :Phone/Fax:Email:Email:Quantity Unit PriceTotal$$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ *Additional Shipping Charges $*Call API for additional shipping costs if you are located in AK, PR or outside of the continental to: Department 9526, Box 30516, Lansing, MI 48909-8016 2019 Order FormInnovative Solutions.

2 Technical ID #Catalog NumberDescriptionIf you would like your Order shipped by department, please use a separate form for each department. Please use additional forms if more lines are & Processing $Visit to view our catalog or call us at 800-333-0958 to request a Order #:Authorized Signature:$99 Order Total $Sub-Total $*Additional shipping charges may apply for AK, PR and all others sent outside of the continental complete the attached form if paying by credit & COAGULATION (continued)MICROBIOLOGY (continued)137 Alcohol$337279 Hematology - 5H$315373 HSV 1 & 2 (molecular)$459138 Ammonia$189238 Hematology - 5S$325339 India Ink$181166 Amniotic Fluid pH$227226 Hematology - 5M$323333 KOH Preparation$184130 Apolipoproteins $181247 Hemochron Jr. ACT - LR$250340 Legionella Antigen $153174 B-Ketone $207248 Hemochron Jr. ACT +$250366 MRSA/Staph aureus (molecular)$109111 Blood Gas$452252 Hemochron Jr.

3 Citrate APTT $373356 MRSA Culture $110112 Blood Gas Plus $494249 Hemochron Jr. Citrate PT$368372 M. tuberculosis (molecular)$357172 Blood Lead - 5$429250 Hemochron Jr. PT$368371 Meningitis Panel$459173 Blood Lead (Waived) - 2$225209 HemoCue White Blood Cell Count$271344 Mycobacteriology Culture $357114 Blood Oximetry $347278 Heparin Assay$271331 Mycology Culture$332140 Cardiac Markers - 5 $350215 i-Stat ACT$285374 Mycoplasma pneumoniae (molecular)$357920 Cardiac Markers - 2 $204208 Lamellar Body Count$230334 Parasitology$281165 Additional Volume Cardiac Markers$166255 Platelet Function - Aspirin Test$245370 Respiratory Panel$498121 Chemistry - Basic$250256 Platelet Function - PRU Test$245348 Rotavirus - 5 $296122 Chemistry - Comprehensive$456214 POC Coagulation A - 5 $264349 Rotavirus - 3 $174141 Chemistry - Additional Volume$114914 POC Coagulation A - 2 $207341 S. pneumoniae Antigen$153125 Chemistry - Endocrinology$222216 POC Coagulation B$269343 Shiga Toxin$235144 Chemistry - waived $181222 QBC Hematology $278364 Strep Pharyngeal (molecular) - 5 $247177 CSF & Body Fluid Chemistry $148223 Reticulocyte Count$242964 Strep Pharyngeal (molecular)

4 - 2 $114170 Cystatin C$306228 Sedimentation Rate - A$184313 Throat Culture - 5 $260148 Ethyl Glucuronide$211201 Sedimentation Rate - B$171952 Throat Culture - 2 $113142 Fetal Fibronectin$368202 Sedimentation Rate - C $171953 Throat Culture - 3 $118131 Fetal ROM$337203 Sedimentation Rate - D$275362 Trichomonas $298135 Fructosamine$159280 Sedimentation Rate - E$308314 Urine Culture - 5 $273126 Glycohemoglobin - 5 $375237 Sickle Cell Screen$205924 Urine Culture - 2 $181127 Glycohemoglobin - 2 $226244 Thromboelastogram$204376 Vaginal Panel$435179 Additional Volume Glycohemoglobin - 5 $102 IMMUNOLOGY357 VRE Culture $110167 Additional Volume Glycohemoglobin - 2 $51421 ANA - EIA & IFA methods $160367 VRE (molecular) $108134 Glycohemoglobin - Whole Blood$217429 ANA - Latex kits$164322 Virology Package - 5 $341128 HemoCue - 5 $252424 ASO $143942 Virology Package - 2 $174928 HemoCue - 2 $153423 Anti-CCP$327933 Virology Package - waived methods - 2 $173133 Immunoassay - 3 $284441 BRCA1/2 Sequencing $949 VERIFICATION PROGRAMS 180 Immunoassay - 5 $398425 C-Reactive Protein - High Sensitivity$189160 Immunoassay - Special $190431 C-Reactive Protein$153145 i-Stat Chemistry - 5 $331419 Diagnostic Allergy$332945 i-Stat Chemistry - waived - 2 $199437 Additional Volume Diagnostic Allergy$92176 Lipid Plus - 5 $250420 H.

5 Pylori Antibody$159976 Lipid Plus - 2 $176439 HCV Viral Load $1,200236 Microalbumin$184440 HIV Viral Load $925147 Neonatal Bilirubin - 5 $212430 HSV-2 Antibody$204129 Neonatal Bilirubin - 2 $150438 Infectious Disease Serology $498169 Procalcitonin$520407 Immunology Package$447J16 ACT - Hemochron - 2 (916)$225171 SHBG and Testosterone $415436 Immunoproteins / C3 & C4 $220J17 ACT - Medtronic 2 (917)$179163 Sweat Analysis $266411 Infectious Mono & Rheumatoid Factor$257A37 Alcohol (137)$266132 Therapeutic Drugs $215410 Infectious Mononucleosis - 5 $164A38 Ammonia (138)$143136 Therapeutic Drugs - add on to Chemistry $94910 Infectious Mononucleosis - 2 $97E17 Auto Blood Bank (517)$561175 Thyroid - Special $209418 Lyme Disease$220E12 Blood Bank (512)$418150 Tumor Markers $424428 Mycoplasma Antibody$189A11 Blood Gas (111)$102146 Urine Adulteration Test$201432 Rapid HIV - 5 $410A12 Blood Gas Plus (112)$102143 Urine Chemistry$310433 Rapid HIV - 2 $209A14 Blood Oximetry (114)$102139 Urine Drug Screen$260408 Rheumatoid Factor$160A40 Cardiac Markers - 5 (140)$179123 Whole Blood Glucose - 5 $260415 Rubella$161J20 Cardiac Markers - 2 (920)$123918 Whole Blood Glucose - 3 $159409 Serum HCG$164C47 C.

6 Difficile Toxin or Antigen - 2 (347)$115 URINALYSIS, MICROSCOPY & OTHER TESTS416 Syphilis Serology$199A21 Chemistry - Basic (121)$102261 Fecal Lactoferrin$169164 Thyroid Antibodies$306A22 Chemistry - Comprehensive (122)$102239 Gastric Occult Blood$184417 Viral Markers $520A44 Chemistry - waived (144)$138233 Provider Performed Microscopy $168 IMMUNOHEMATOLOGYB17 Coagulation (217)$143287 Add-on PPM photographs$30511 ABO / Rh$301E14 DAT (514)$164260 Rapid Urease$155516 Antibody Elution$561B46 D-dimer Quantitative (246)$123273 Urine Crystals$346519 Antibody Titer - A$276B84 Fecal Occult Blood (284)$96258 Urine Eosinophils$77520 Antibody Titer - D$276B39 Gastric Occult Blood (239)$133289 Add-on Urine Eosinophils photographs$30521 Antibody Titer - AD$378A27 Glycohemoglobin - 2 (127)$215232 Urinalysis & HCG$147517 Automated Blood Bank$561J12 Group A Strep Antigen 2 (912)$97272 Urinalysis & HCG - I$181537 Auto Blood Bank w/ Electronic Crossmatch$872B20 Hematology - 5C2 (220)$271235 Urine HCG - Qualitative $164512 Blood Bank$431B21 Hematology - 3 (221)$271234 Urine Sediment$57532 Blood Bank w/ Electronic Crossmatch$735B27 Hematology - 3S (227)$271288 Add-on Urine Sediment photographs$30514 Direct Antiglobulin Testing $209B30 Hematology - 5C (230)$311270 Automated Urine Microscopy - I$206534 DAT - Automated $250B31 Hematology - 5A (231)$311271 Automated Urine Microscopy - S$206518 Educational Blood Bank$200B38 Hematology - 5S (238)$313251 Waived & PPM Package$236515 Fetal RBC $306B40 Hematology - 5B (240)$311 ANDROLOGY513 Rh Slide Test$171B42 Hematology - 5D (242)$311154 Antisperm Antibody $268 MICROBIOLOGYJ28 HemoCue - 2 (928)$113162 Post-Vasectomy Sperm Analysis $268335 Acid Fast Smears$206B47 Hemochron Jr.

7 ACT-LR (247)$194151 Sperm Count$268324 Affirm VP$369B48 Hemochron Jr. ACT+ (248)$194152 Sperm Morphology$268359 Bacterial Vaginosis$179A33 Immunoassay - 3 (133)$215161 Sperm Motility$308321 Basic Bacteriology Package $286A60 Immunoassay - Special (160)$133153 Sperm Viability$268361 Blood Culture - Add-on$194B15 i-STAT ACT (215)$204 HEMATOLOGY & COAGULATION336 Blood Parasites$406A45 i-STAT Chemistry - 5 (145)$164211 ACT (Hemochron/Helena) - 5 $357368 Blood Pathogen Panel$495J45 i-STAT Chemistry - waived - 2 (945)$97916 ACT (Hemochron/Helena) - 2 $266363 Bordetella pertussis/parapertussis (molecular)$357A29 Neonatal Bilirubin - 2 (129)$148212 ACT (Medtronic) - 5 $357360 Campylobacter - Add-on$148B14 POC Coagulation A - 5 (Verification)$209917 ACT (Medtronic) - 2 $266317 Candida Culture$329J14 POC Coagulation A - 2 (Verification)$133259 Advanced Blood Cell ID $184350 C. difficile Toxin or Antigen - 5 $215B16 POC Coagulation B (Verification) (216)$204224 Blood Cell ID (CMS Scored)$59347 C.

8 Difficile Toxin or Antigen - 2 $148B33 PPM (233)$128225 Blood Cell ID (Not CMS Scored)$59316 Chlamydia Antigen - 5 $322D33 Rapid HIV - 2 (433)$143286 Add-on Blood Cell ID photographs$30930 Chlamydia Antigen - 2 $113D09 Serum HCG (409)$131206 Body Fluid Cell Count - C$209311 Chlamydia/GC (molecular)$396A36 TDM - add on to Chem (136)$62207 Body Fluid Cell Count - I$209328 Comprehensive Bacteriology$320B32 Urinalysis & HCG (232)$128168 Body Fluid Microscopy$68345 Cryptococcal Antigen$169A39 Urine Drug Screen (139)$194181 Add-on Body Fluid Microscopy photographs$20332 Dermatophyte Culture$266B35 Urine HCG-5 (235)$128277 Cell Count & Body Fluid Crystals$289369 GI Panel$461C22 Virology Package (322)$245217 Coagulation (PT, APTT, Fibrinogen)$194342 Giardia & Crypto Antigen - 5 $268J33 Virology Package - waived - 2 (933)$123281 Coagulation, Supplemental $347932 Giardia & Crypto Antigen - 2 $159B51 Waived & PPM Package (251)$181282 Additional Volume Coagulation, Supplemental $107315 GC/Group B Strep Culture - 5 $245A23 Whole Blood Glucose - 5 (123)$215245 D-dimer - Qualitative$153929 GC/Group B Strep Culture - 2 $113J18 Whole Blood Glucose - 3 (918)$115246 D-dimer - Quantitative$155320 Gram Stain (slides)$179X23 Extra Results WBG - 5 (123)$0284 Fecal Occult Blood$120330 Additional Gram Stain (slides)$113X18 Extra Results WBG - 3 (918)$0285 Fecal Occult Blood - add on$22329 Gram Stain - Direct Smears$184X51 Extra Results WBG waived Package (251)$0210 Fetal Hemoglobin - gastric fluid$250319 Gram Stain - Vaginitis$298 SUPPLEMENTAL ITEMS229 Flow Cytometry $439312 Group A Strep Antigen - 5 $199957 API 3-Ring Binder ( Customers Only)

9 $15221 Hematology - 3$284912 Group A Strep Antigen - 2 $108958 API 3-Ring Binder Tabs Only$5227 Hematology - 3S$276913 Group A Strep Antigen - 3 $128 REG Shipping & Processing$99231 Hematology - 5A$315365 Group B Strep (molecular) - 5 $247 240 Hematology - 5B$311965 Group B Strep (molecular) - 2 $114230 Hematology - 5C$315375 HPV (molecular) - 5$498220 Hematology - 5C2$273975 HPV (molecular) - 2$357242 Hematology - 5D$311351 H. pylori Antigen, Stool$284 CMS only allows PT for one instrument/method. The programs below are to test and report another instrument/method after the PT due date. No results will be reported to CMS or other regulatory agencies. The primary catalog number is shown in parentheses next to each verification program. Contact us at 800-333-0958 or if you need assistance. Some analytes within this program are not CAP accepted. See our online catalog for the most recent list of CAP accepted shipping charges may apply to Alaska and countries outside of the Proficiency INSTITUTE - 2019 PRICE LISTI nstrument NameAPI Catalog NumberBody Fluid Cell CountAbbott Cell-Dyn-all models206 Coulter AC-T, HmX, LH, MAXM, Unicel DxH- all models206 Iris iQ207 Siemens Advia 120/2120206 Sysmex XE, XN, XS, XT-all models206 HematologyAbbott Cell-Dyn 1400 through 1800221 Abbott Cell-Dyn 3000 through 5000242 Abbott Cell-Dyn Emerald221 Abbott Cell-Dyn Emerald 22242 Abbott Cell-Dyn Ruby, Sapphire242 CDS Medonic CA221 CDS Medonic M-Series227 Coulter AcT-5231 Coulter Ac-T all 3 part differential models221 Coulter HmX, GEN-S220 Coulter JT, T- all models221 Coulter LH500, MAXM, STKS220 Coulter LH-750/755/780/785230 Coulter Micro Diff- all models221 Coulter UniCel DxH 300221 Coulter UniCel DxH 600.

10 800230 Danam Datacell- all models221 Diatron Abacus 5242 Drew (Danam) Excell 16221 Drew D3, Evolution221 Drew Excell 22, 2280241 HemoCue- all models (for WBC only)209 Horiba ABX 9000, 9100, Micros, Minos - all models221 Horiba ABX Pentra- all models231 Humacount221 Infolab Excell 16, I-1600, I-1800- all models221MD Mascot 800221 Mindray 5000 Series226 Mindray BC - all models221 QBC Autoread, Autoread Plus222 QBC Reader - Manual222 Siemens Advia 120, 2120- all models240 Siemens Advia 56242 Siemens Advia 60221 Sysmex KX Series, pocH-100i227 Sysmex XE, XN, XS, XT - all models238 Sysmex XP-300227 Hematology Instrument 800-333-0958 Sedimentation RateAlcor i-Sed203BD Seditainer228 Chase Westergren 830 SO228 Dispette, Dispette 2228 Globe Scientific- all methods228 Griener SRS, SRT228 HemaTech ESR STAT PLUS, STAT 180202 Life Science Technologies ESRA228 MiniVes228 Polymedco Sedimat 15, 15 Plus201 Polymedco Sedimat/Sediplast228 Sedifast, Sediplast, Sediten, Seditube228 StaRRsed Compact228 Statspin ESRA-10228 Streck / Analys ESR.