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Laboratory Profile Registration Form
Please follow the instructions carefully since the submission of incomplete applications will delay the processing and issuance of the registration.
If your laboratory already has an AHFoZ Payee number, please indicate here:
2. GENERAL INFORMATION:
Laboratory Name
HPA Number:
City Council Business Number:
Laboratory Address (Physical Location of Laboratory):
Province:
District:
City:
Postal Address):
City:
Telephone Number:
FAX Number:
Practitioner In Charge Name :
Laboratory E-mail Address:
Basic Qualification:
Spec/Post Basic Qualification:
Telephone Number:
E-mail Address:
Indicate the Additional Support Team:
Practitioner In Charge Name :
Practitioner In Charge Name :
Basic Qualification:
Basic Qualification:
Spec/Post Basic Qualification:
Spec/Post Basic Qualification:
Telephone Number:
Telephone Number:
E-mail Address:
E-mail Address:
3. LABORATORY TYPE:
Select from the list below that best describes your laboratory
Acute Related Referrals
Hospital
Ambulatory Surgery Center
Industrial
Ancillary Testing Site in Health Care
Facility/Hospital Extension Clinic
Maternal Health
Blood Bank
Intermediate Care Facility for the Mentally Retarded
Community Clinic
Mobile Laboratory
Comprehensive Outpatient Facility Pharmacy
Correctional Facilities
Physician Referrals
Chronic Disease Dialysis Facility Practitioner Referrals
Emergency Based Pathology
Public Health Laboratory
Health Fair
Rural Health Clinic
Health Maintenance Organization School/Student Health Service
Home Health Agency
Tissue Bank/Repositories
Other (Indicate)
Indicate
5. AFFILIATION:
If your laboratory is affiliated with a laboratory holding an AHFoZ Payee Number, provide the name, address, and AHFoZ Payee Number. Do not provide the name and AHFoZ Payee Number of your reference laboratory.
AHFoZ Number:
Name of Laboratory:
Address:
Province:
District:
City:
5.1 AFFILIATION:
If your laboratory is affiliated with a laboratory holding an AHFoZ Payee Number, provide the name, address, and AHFoZ Payee Number. Do not provide the name and AHFoZ Payee Number of your reference laboratory.
AHFoZ Number:
Name of Laboratory:
Address:
Province:
District:
City:
7. TEST PROCEDURES REQUESTED:
Check off all tests that you DO NOT to perform
Adenovirus
Erythrocyte Sedimentation Rate (ESR) Occult Blood
Aerobic/Anaerobic Organisms-Vaginal Ethanol
Ovulation Tests
Alanine Aminotransferase (ALT) Follicle Stimulating Hormone (FSH)
pH
Albumin
Fructosamine
Phosphorous
Alkaline Phoshatase (ALP)
Gamma Glutamyl Transferace (GGT) Platelet Aggregation
Amylase
Full Blood Count
Potassium
Aspartate Aminotransferase (AST) Glucose
Allegry Test
Glycosylated Hemoglobin
Pregnancy Test (Urine)
B-Type Natriuretic Peptide (BNP)
HDL Cholesterol
Protime
Bacterial Vaginosis, Rapid Helicobacter Pylori
RBS (Radmon Bloos Sugar)
Bladder Tumor Associated Antigen Hematocrit
Saliva Alcohol
Blood Urea Nitrogen (BUN) Hemoglobin
Sodium
Breath Alcohol (FDA OTC Devices Only)
HCV, Rapid
Strep Antigen Test (Rapid)
Calcium
HIV, Rapid
Cytology
Histology
Thyroid-Stimulating Hormone (TSH)
Calcium, Ionized
Influenza
Total Bilirubin
Carbon Dioxide
Ketones
Total Protein
Catalase (Urine)
Lactic Acid (Lactate)
Trichomonas, Rapid
Chloride
LDL Cholesterol
Triglycerides
Cholesterol
Lead (*Submit Protocol w/App.) Urinalysis
Creatine Kinase (CK)
Microalbumin
Other:
Other(specify)
9. PROVIDER-PERFORMED MICROSCOPY (PPM) PROCEDURES REQUESTED:
Check off all Procedures that you DO NOT intend to perform. NOTE: Only providers (physicians, nurse practitioners, nurse midwives and physician
istants) may perform testing. Direct wet mount preparations for the presence or absence of bacteria, fungi, parasites, and human cellular elements
Post-coital direct, qualitative examinations of vaginal or cervical mucous
Fecal Leukocyte examinations
Potassium hydroxide (KOH) preparations
Fern tests
Qualitative semen analysis (limited to the presence/absence of sperm and detection of motility)
Pinworm examinations
Urine sediment examinations
Other:
Other
5.1Equipment Used:
List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine
Name of Machine
Make and Serial Number:
Test Conducted:
Commissioning Done By :
Date
MM slash DD slash YYYY
Maintenance Schedule:
5.1Equipment Used:
List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine
Name of Machine
Make and Serial Number:
Test Conducted:
Commissioning Done By :
Date
MM slash DD slash YYYY
Maintenance Schedule:
5.1Equipment Used:
List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine
Name of Machine
Make and Serial Number:
Test Conducted:
Commissioning Done By :
Date
MM slash DD slash YYYY
Maintenance Schedule:
5.1Equipment Used:
List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine
Name of Machine
Name of Machine
Name of Machine
Name of Machine
Date
MM slash DD slash YYYY
Maintenance Schedule
10. BANKING DETAILS
I/We declare the Banking Details below are correct and authorize that they be used by the medical schemes and their administrators for reimbursement of claims
Practice Name
Name of Bank
Name of Branch
Account Name
Branch Code
Account No.
Type of Account
Provider's Name
Please upload your supporting documents here.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 15.
11. CERTIFICATION.
I understand that by signing this application form, I agree to any Accreditation visit made by the to verify or confirm the information provided herein or adjunctive to this application, and any accreditation in connection with my laboratory registration, a complaint or incident report made known to the Department. Registration under this subdivision may be denied, limited, suspended, revoked or annulled by the Department upon a determination that a laboratory services registrant: (i) failed to comply with the requirements of this subdivision; (ii) provided services that constitute an unwarranted risk to human health; (iii) intentionally provided any false or misleading information to the Department relating to registration or performing laboratory services; or (iv) has demonstrated incompetence or shown consistent errors in the performance of examinations or procedures. If additional information is requested, I will provide it. Further, I understand that, should this application or my status be investigated at any time, I agree to cooperate in such an verification.
Laboratory test registrants shall: (i) provide only the tests and services listed on the registration issued by the Department hereunder; (ii) advise the Department of any change in the registrant's name, ownership, location or qualified health care professional or laboratory director designated to supervise testing within thirty days of such change; (iii) provide the department with immediate access to all facilities, equipment, records, and personnel as required by the Department to determine compliance with this subdivision; (iv) comply with all public health law and federal requirements for reporting reportable diseases and conditions to the same extent and in the same manner as a clinical laboratory; and (vi) designate a qualified health care professional or qualified individual holding a certificate of qualification pursuant to section five hundred seventy-three of this title, who shall be jointly and severally responsible for the testing performed.
By signing this application, I hereby attest that the information I have given as a basis for obtaining a Laboratory Registration is true and correct, that I have read the relevant rules and regulations, and that I accept responsibility for the tests indicated in Section(s Provider-Performed Microscopy (PPM) Procedures Requested of this application.
Print Name of Laboratory Director
Print Name of Laboratory Director
Signature of Laboratory Director
Reset to re-sign.
Signature of Laboratory Director
Date
MM slash DD slash YYYY
Date
Print Name of Person Completing this Form
Print Name of Person Completing this Form
Signature of Person Completing this Form
Reset to re-sign.
Signature of Person Completing this Form
Date
MM slash DD slash YYYY
Date
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