Genetic Testing Resource

and Quality Consortium

Application for Membership-Laboratories

Laboratory Name
Address
City, State, Zip

Is your lab owned by a Health System? ☐Yes ☐No

If Yes, which Health System? Click here to enter text.

If No, with which Health System(s) are you affiliated? Click here to enter text.

All participating labs must be affiliated with a BCBSM Physician Organization (PO). With which PO(s) is your lab affiliated? Click here to enter text.

Number of physicians and doctoral-level scientists in your Laboratory
Number of Laboratory Scientists (pre-doctoral level) in your Laboratory
Number of Molecular Diagnostic/Genetic Tests
performed over the past 12 months
Please provide the name and contact information for your GTRQC Leadership Team below, including Clinical Champion, Pathology Champion, Genetics Champion, Quality Champion, Administrative Lead, and PO Contact as well as any others you feel important for your team. *Not all teams will have all Champions, but must have at least one Physician Champion in the Clinical, Pathology or Genetics roles.
Team Member Name / Member Role / Phone Number / E-Mail
Clinical Champion*
Pathology Champion*
Genetics Champion*
Quality Champion
Administrative Lead
PO Contact

By submitting this application, our Laboratory acknowledges that we are agreeing to actively participate in the activities of the collaborative. Participation includes, but not limited to:

1.  Sending Physician Champions and any interested team members to the GTRQC Collaborative meetings, to be scheduled on a quarterly basis, and any relevant meetings/conference calls or required training sessions. Laboratories are responsible for making their own travel arrangements and for covering the cost of travel and lodging.

2.  Providing protected time for members of the team to actively participate in quality improvement efforts. We expect Champions to be able to effect change at the laboratory.

3.  Providing Coordinating Center with quality-improvement data, as requested and defined by a Data Use Agreement, in a timely and cooperative fashion.

4.  Responding to Coordinating Center requests within the time frames indicated.

By signing below, I acknowledge that I fully understand and commit to the terms in the application and as laid out in the GTRQC Initiative Plan. I also acknowledge that I have the authority to enter into this Agreement on behalf of this practice unit, or if not, the authorized individual (Laboratory Director or Executive Director) has also signed below.

Clinical Champion / Date
Pathology Champion / Date
Genetics Champion / Date
Authorized Signer / Date

For the PO Contact:

By signing below, I acknowledge that I fully understand and commit to the terms in this application and will commit the resources needed to fully participate in the Collaborative. If enrolled, should there be any future data abstraction support for this initiative, it will be made to my PO in its annual PGIP distribution. These payments will be forwarded to the enrolled laboratory as it is meant to cover the costs associated with the laboratory’s start-up efforts for participation in the GTRQC.

Note: While BCBSM believes there should be no tax consequences to the PO when this pass-through is paid, we suggest that you consult your tax advisors to confirm this and determine if there is anything else you may need to do to appropriately forward these payments.

PO Contact Name
PO Contact Title
Signature / Date

Participant List

Please provide a list of all Clinicians, Pathologists, Genetics Specialists, and Other Providers (Laboratory Scientists, etc.) within your laboratory who will be participating in the GTRQC. Attach additional pages, if necessary.

Name / Physician Number (NPI)
If applicable / Specialty / Phone / E-Mail

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