<p> Massachusetts General Hospital CLIA & Accreditation Request Form</p><p>Instructions: Please e-mail or fax the completed form to [email protected] / (617) 726-1996. 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 Cliff Leuschen (617) 726-3758. Date: I understand 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.</p><p>1) X: (Request acknowledgement: signature or typed name required) 2) Reason for request (please check all that apply) Testing performed by MGH labs (Department of Pathology Service only) Testing performed by MGH labs (Non-pathology) Research Study / IRB No: MGH Affiliate (MGH offsite) Other: 3) Previous MGH CLIA Certificate Number: 4) YOUR Name: 5) YOUR institution: 6) YOUR street address: 7) YOUR city, state, zip code: 8) YOUR phone number: 9) YOUR e-mail AND fax: 10) Information Requested: CLIA Certificate Joint Commission Accreditation Other -- Please specify: 11) Name of YOUR staff requesting our services: 12) MGH Laboratory providing testing / consultation: 13) MGH Consult or contact name: 14) Please list the tests performed by MGH: The names of the tests performed are required in order to receive a copy of a certificate or accreditation: If you are unable to provide the test names, please consult the requesting physician. If MGH does not perform tests for your organization, please list the types of consults, consulting physicians name, study details, etc. </p><p>Version 6.2 / Nov 2009 MGH Pathology Service Please type or copy this URL in your web browser to see the reference ranges:</p><p> http://labtest.partners.org/ReferenceRanges.htm</p><p>Please type or copy this URL in your web browser to see test pricing:</p><p> http://mghlabtest.partners.org/ResearchRates.htm</p><p>Please type or copy this URL in your web browser to see information on setting up a study:</p><p> http://mghlabtest.partners.org/Study.htm</p><p>MGH Departments of Pathology, 55 Fruit Street, GRB-536, Clinical Laboratory Improvement Amendments (CLIA) ID No. 22D0650226:</p><p> Blood Transfusion</p><p> Core Laboratory: </p><p> o Chemistry</p><p> o Hematology</p><p> o Coagulation</p><p> Cytopathology</p><p> Diabetes</p><p> Histocompatibility</p><p> Histology</p><p> Immunology</p><p> Immunopathology</p><p> Microbiology</p><p> Molecular Diagnostics</p><p> Special Coagulation</p><p> Surgical Pathology</p><p>Version 6.2 / Nov 2009 MGH Pathology Service</p>