Customer Change Form Enrollment InformationThis request is for enrollment year:(Required) This request applies to the following:(Required) Add/Drop Product Update Correspondence or Demographic Information Update Accreditation Agency Information Identification InformationWSLH PT ID (7 digits)(Required) Current/previous account ID (if known)CLIA ID If application in progress, enter "Pending"Contact InformationPlease enter the contact information of the person completing this formFacility Name(Required) Name(Required) First Last Phone(Required)Example: (123) 456-7890Email(Required) Request To Add And/Or Drop POC Package ProductsAdd/Drop PT03400 POC Package Add Drop Add PT03400 | Point of Care / PPMP PackageSelect PT03400, then check two-to-four options below PT03400 | Price: $320 Drop PT03400 | Point of Care / PPMP Package Select PT03400, then check all relevant options below POC Package Options PT03075 | Fecal Occult Blood (OC) PT01881 | Glucose Whole Blood (WBG) PT05135 | Group A Strep Antigen - Waived Methods (WS) POC Package Options PT02151 | Hematocrit - Waived Methods (HW) PT01451 | Hemoglobin - Waived Methods (HWG) PT01456 | Hemoglobin - HemoCue Hb 301 & Hb 801 Waived (HWH) POC Package Options PT04222 | Mono Immunoserology - Waived (MW) PT03175 | Provider Performed Microscopy (PM) PT03265 | Urinalysis/Urine hCG (UR) Add/Drop PT03401 POC Package - Additional Items Add Drop Add PT03401 POC Package - Additional Items Select PT03401, then choose from the options below, by indicating the desired quantity for each PT03075 | Add-on moduleFecal Occult Blood (OC) Price: $90.00 Quantity: PT01881 | Add-on moduleGlucose Whole Blood (WBG) Price: $90.00 Quantity: PT05135 | Add-on moduleGroup A Strep Antigen - Waived Methods (WS) Price: $90.00 Quantity: PT02151 | Add-on moduleHematocrit - Waived Methods (HW) Price: $90.00 Quantity: PT01451 | Add-on moduleHemoglobin - Waived Methods (HWG) Price: $90.00 Quantity: PT01456 | Add-on moduleHemoglobin - HemoCue Hb 301 & Hb 801 Waived (HWH) Price: $90.00 Quantity: PT04222 | Add-on moduleMono Immunoserology - Waived (MW) Price: $90.00 Quantity: PT03175 | Add-on moduleProvider Performed Microscopy (PM) Price: $90.00 Quantity: PT03265 | Add-on moduleUrinalysis/Urine hCG (UR) Price: $90.00 Quantity: Drop PT03401 | POC Package - Additional Items Select PT03401, then check all relevant options below POC Package Options PT03075 | Fecal Occult Blood (OC) PT01881 | Glucose Whole Blood (WBG) PT05135 | Group A Strep Antigen - Waived Methods (WS) POC Package Options PT02151 | Hematocrit - Waived Methods (HW) PT01451 | Hemoglobin - Waived Methods (HWG) PT01456 | Hemoglobin - HemoCue Hb 301 & Hb 801 Waived (HWH) POC Package Options PT04222 | Mono Immunoserology - Waived (MW) PT03175 | Provider Performed Microscopy (PM) PT03265 | Urinalysis/Urine hCG (UR) Request To Add And/Or Drop All Other ProductsAdd/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add/Drop Product Add Drop Product Name/Item # Please add the product name and item # here, and separate both entries with a "/"Year/Event(s) QuantityN/A12345678910Add Products: Payment InformationVISA/MC: If you wish to pay by credit card, please wait for your invoice for instructionsPurchase Order (PO#) - optionalDropped ProductsAll cancellations must be submitted in writing at least 30 days prior to scheduled shipment date. A credit will be applied to your account, if appropriate. The annual processing fee is non-refundable. Refund requests will be handled on a case by case basis by the accounts receivable department.Reason for drop No longer performing test Initial Incorrect order Changed instrument or kit Site closed Other Request To Update Correspondence/Demographic InformationChange Pertains To (check all that apply) Billing Information Shipping Information Send Reports to Information Facility Name Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneExample: (123) 456-7890FaxEmail Request To Update Accreditation Agency(ies)Add/Remove Accred. Agencies Add Remove Agency Name ID Number Effective Date DD slash MM slash YYYY Add/Remove Accred. Agencies Add Remove Agency Name ID Number Effective Date DD slash MM slash YYYY Add/Remove Accred. Agencies Add Remove Agency Name ID Number Effective Date DD slash MM slash YYYY Score Transmission To Accreditation Agency(ies)All applicable scores will be sent to designated agencies by default unless specified below.Do NOT send the following scores to agencies Δ
