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2022 U.S. MLE Proficiency Testing Order Form

Part I

Note: Items marked with * are required

* Order Type:  Renewal       New Order
* MLE ID# (MLE ID# required for Renewal)

Auto Renewal Program:
Check this box to enroll in the Auto Renewal Program

By using MLE's Express Renewal, I acknowledge that:

  • I am renewing my order exactly as it appeared for the 3rd testing event's original shipment.
  • I will receive an Order Verification to confirm my renewal.
  • I will review my OV for accuracy of modules and contact information.
  • Changes may be made to modules as long as renewal is made 4 weeks before the upcoming shipment. (Please contact MLE Customer Service if you need assistance with this process).

Please complete the contact information to confirm your lab's identity:


1. Bill To:
*Attn To
*Facility Name
*Address Line 1
Address Line 2
*City
State
Zip
*Country
*Phone
*Fax
*Email

2. Lab Director:
*Director

3. Ship To (no P.O. boxes):
Same as billing address:
*Attn
*Facility Name
*Address Line 1
Address Line 2
*City
State
Zip
*Country
*Phone
*Fax
*Email

4. * CLIA ID#:
I have my CLIA ID#
D
Pending
No CLIA license required

5. Send a copy of my proficiency testing results to:
CMS (If checked, must provide CLIA ID# or select 'Pending' in Section 4)
COLA
ID#
TJC
ID#
State Agency
ID#
Other (If checked, complete mailing information below)
*Name
Company
*Address Line 1
Address Line 2
*City
State
Zip
*Country
*Phone
*Fax
*Email
The person listed above is a consultant

6. Select the products that you wish to order:
Important: Please review our Shipment Information.
Hematology Quantity Event
Please review prior to selecting your Hematology Module.
210 Hematology Module
212 Hemoglobin/Hematocrit/WBC
213 Hemoglobin/Hematocrit - Waived
215 Hemoglobin/Glucose - HemoCue
223 Hematology with 5-part Diff - Abbott Cell-Dyn
224 Hematology - Sysmex 3-Part Diff
225 Hematology with 3-Part Diff
226 Hematology with 5-Part Diff - Coulter Instruments
228 Hematology with 5-part diff - AcT 5 and Pentra
229 Hematology with 5 or 6-Part Diff - Sysmex Instruments
230 Blood Cell Identification(add-on)
231 Blood Cell Identification
240 Reticulocyte Count
247 Sedimentation Rate
248 Sedimat 15 ESR
250 Fluid Cell Count/Crystals
Coagulation Quantity Event
320 Coagulation Module
324 Roche CoaguChek XS INR
328 i-Stat Prothrombin Time
330 CoaguChek XS Plus/Pro PT/INR
331 CoaguChek XS Plus/Pro PT/INR - Waived
Blood Bank Quantity Event
451 ABO & Rh Factor (D Type)
452 Blood Bank 1
453 Blood Bank 2
Urinalysis/PPM/Occult Blood Quantity Event
530 Urinalysis Module
531 Urinalysis Dipstick
532 Urine Sed ID
533 Urine Sed ID - Add on
534 Provider-Performed Microscopy (PPM)
535 PPM - Add on
536 Urine Microalbumin/Creatinine - Add on
537 Fecal Occult Bld - Add On
538 KOH Slides
539 Urine Microalbumin/Creatinine
540 Urine hCG - Add on
541 Urine hCG
542 Fecal Occult Blood
Waived Testing Packages Quantity Event
901 Waived and PPM Package
902 Basic Waived and PPM Package
Microbiology Quantity Event
630 Bacteriology 1
640 Bacteriology 2
641 Throat Culture (TC)
643 Urine Culture (UC)
645 Urine/Throat Culture
646 Genital Culture
647 Urine Presumptive ID/Colony Count
648 Colony Count Only
650 Gram Stain
651 Miscellaneous Cultures – Add-on
652 Urine Presump ID/TC
653 Genital/Urine Culture
660 Strep A Antigen
662 Strep A Antigen - Waived
668 Affirm® III VP (DNA)
673 Chlamydia/GC (EIA, DNA) - Add on
675 Chlamydia/GC (EIA, DNA )
678 Dermatophyte Culture
680 Respiratory Antigen Detection - Waived
681 Respiratory Antigen Detection
682 C. difficile/Rotavirus Antigen Detection
683 Cryptosporidium/G. lamblia Antigen Detection
686 Legionella Antigen Detection
687 Streptococcus Pneumoniae Antigen Detection
688 SARS-CoV-2 Antigen
689 SARS-CoV-2 Molecular
690 PVA Slides – Add-on
691 Parasitology
692 Bacterial Vaginosis - Waived
693 Trichomonas Vaginalis - Waived
695 MRSA Culture
Immunology Quantity Event
750 Immunology Module
751 Rheumatology Module
755 Infectious Mono - Waived
761 Infect Mono/Rheumatoid Factor
762 Infectious Mononucleosis
763 Rheumatoid Factor
764 C-Reactive Protein (CRP)
765 HS-CRP
770 Specific Allergen Testing
771 Rubella
772 Syphilis Serology
773 Diagnostic Allergy
775 Viral Markers
776 CRP-Add-on
777 HS-CRP Add-on
780 H. pylori Antibody
781 Mycoplasma
782 ANA Panel
783 ANA Panel – Add-on
784 Complement/Immunoglobulins
790 Anti-HIV - waived
791 Anti-HIV
792 SARS-CoV-2 Serology
Chemistry Quantity Event
810 Chemistry Module
811 Lipid Panel/Glucose - Waived
812 Waived Chemistry Panel
813 Comp. Metabolic Panel
817 i-STAT Chemistry 1
818 i-STAT Chemistry 2
824 Thyroid Profile
826 Lipid Profile
831 Therapeutic Drug - Add on
832 i-STAT Chemistry - Waived
833 Waived Chemistry Panel - Add-on
835 Serum Alcohol/Acetone
836 Ammonia
838 Blood Lead - Waived
841 Neonatal Bilirubin
845 Cardiac Markers
846 BNP/D-Dimer
847 Blood Gases
850 Glycohemoglobin
851 Afinion Glycohemoglobin
854 SHBG/Testosterone
859 PSA - Add On
860 Endocrinology/Hematology/Oncology
861 PSA
862 Tumor Markers
863 Endocrinology 2
864 Thyroid Antibodies
865 Serum hCG
866 Serum hCG - Add on
868 Urine Drug Screen
870 Whole Blood Glucose
871 Whole Blood Glucose - Waived
872 Urine Chemistry
873 Ethyl Glucuronide - Add-on
874 Adulterated Urine - Add-on
Lab Supplies/Services Quantity Event
108 MLE Binder
121 1mL Pipette
126 Pipette pump
142 G2 NIR Subscription MLE Discount


7. MLE Discount Offers - See If You Qualify! Eligibility Requirements

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

ACP - ACP Members - SAVE $90
ACP ID#: (Required if ACP Offer selected)
Multisite - SAVE 5% (with 5 or more enrolled labs)
(To receive this discount, please complete Section 5 on this form)
Management Group Code (If known):
Consultant - SAVE 5% (with 5 or more enrolled labs)
(To receive this discount, please complete Section 5 on this form)
Consultant Group Code (If known):
Government - SAVE 10% (FQHC/IHS)
COLA - SAVE $90 (NEW to MLE with COLA Membership)
COLA ID#: (Required COLA Offer selected)
NEW - SAVE $90 (NEW to MLE with $500 minimum order)
Not applicable

8. * How Did You Hear About MLE's Proficiency Testing?
Which site:
Enter Priority Code from the box on the 'Especially For You' section of the mailer:
If Other Please Specify:

9. * Laboratory Type
If Other Please Specify:

Comments (DO NOT ENTER CREDIT CARD INFORMATION):