Clinical Lab Consulting, LLC.

Phone: 847-682-0024
Please enter your contact information:

Last Name: First Name: Phone Number: Email Address:

  1. Do you currently have a Physicians Office Lab (POL) in your practice?

    2. Yes No

  2. If yes, please list the accreditation agency that you are certified with (COLA, CAP, JACHO, State, etc.).

  3. What is your proficiency institution (AAB, API, CAP, AAFP-PT, etc.)?

  4. How many physicians/practitioners are affiliated with this practice?

  5. Who is the laboratory director and under what name is (or going to be) the CLIA Certificate/License issued?

  6. Does this lab serve only your patient group or does it also serve as a Reference Laboratory?

    7. Only My Patients As a Reference Lab My Patients and as a Reference Lab

  7. What is the highest level of testing performed at your laboratory, or going to be performed?

    8. High Complexity Moderate/PPM Waived Testing

  8. What is your current test menu or the test menu you are interested in developing?

  9. Can you approximate the test volume?

    10. Day Month Year

  10. Who will you be using as your reference lab?

  11. Do you have any lab personnel and what are they by qualification? (Example: MT, MLT or Technical Lab Assistants, etc.)

  12. What instrumentation are you currently using, or going to use?

  13. Do you have a LIS? If yes, what is the LIS you are using?

    14. Yes No

  14. Who is responsible for phlebotomy? (Lab personnel, Nursing, Medical Assistants, etc).

  15. When was your last inspection and what organization conducted it (if any)?

  16. Do you currently have a Technical Consultant that monitors your lab (if you have a lab)?

    17. Yes No

  17. When was your last audit (if you have a lab)?