Massachusetts GeneralHospital

CLIA & Accreditation Request Form

FORM INSTRUCTIONS:

Please returnthe completed form to / fax (617) 726-1996, and CLIA information will be sent within the next five business days. Incomplete requests cannot be processed and will delay transmittal. If you have any questions, please contact CliffLeuschen at (617) 724-0633.

Date:

I acknowledge that the certificate being requested is to be used for testing performed by the MGH labs named on the certificate. The certificate does not cover tests performed at other locations and is provided for the purpose of reference and should not be distributed or posted on line.

1)X:

(Request acknowledgement: signature or typed name required)

2)Reason for Request: Please check all boxes that apply and provide details.

Lab Testing: MGH Pathology Lab: orMGH Non-Pathology. Samples sent for testing by MGH. Please list the names of all testsperformed by MGH: The names of the tests performed are required in order to determine which lab performs the test and to send the appropriate CLIA:

Test Names:

(If you are unable to provide the test names, please consult the requesting physician)

Name of MGH Lab providing testing:

Name of MGH Lab Contact:

Study: Samples sent for Research: please provide Study Number(IRB No):

and the Test Names:

Consult: Samples sent for an MGH consult. Please list the MGH Pathologist’s name:


andtype of consult:

Other Reason:

3)Previous MGH CLIA Certificate Number:

4)YOUR staff requesting info :

(if different from above)

5)YOUR institution:

6)YOUR street address:

7)YOUR citystatezip code:

8)YOUR phone number:

9)YOUR e-mailAND fax:

10)Information Requested: CLIA Certificate Accreditation Other

Please specifyother:


Please type or copy this URL in your web browser to see the reference ranges:

Please type or copy this URL in your web browser to see test pricing:

Please type or copy this URL in your web browser to see information on setting up astudy:

MGH Department of Pathology, 55 Fruit Street, GRB-536, Clinical Laboratory Improvement Amendments (CLIA) ID No. 22D0650226:

  • Blood Transfusion
  • Clinical Research Core
  • Core Laboratory:
  • Chemistry
  • Hematology
  • Coagulation
  • Cytopathology
  • Diabetes
  • Histocompatibility
  • Histology
  • Immunology
  • Immunopathology
  • Microbiology
  • Molecular Diagnostics
  • Phlebotomy
  • Special Coagulation
  • Surgical Pathology

Version 6.2 / Nov 2009 MGH Pathology Service