Order Form Instructions
The following lettered items correspond to specific sections of the order form below and on page 11.
Use demographic pages 1 and 2 only to submit changes. Note: If you need to make changes to any section of the order form, please print new information using blue or black ink clearly in the boxes provided.
Part 1 - Demographic Information (Pages 1 and 2)
A Laboratory Information
Please add or verify the laboratory director, laboratory contact name, phone number, fax number, and e-mail address. Print any changes in the boxes provided.
B CLIA/CLIP Number
Subscribers in the United States should confirm or provide the laboratory’s CLIA identification number. This number is assigned by the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA) and can be obtained from your laboratory director. If you do not currently have a CLIA ID number, contact your CMS Regional Office. Do not delay your order while waiting for your CLIA ID number.
Department of Defense subscribers are to verify or submit their CLIP Number. All other customers will leave the CLIP Number blank.
C “Bill To” and “Ship To” Address
Check the accuracy of the “Bill To” and “Ship To” information. Please make any necessary changes or add new information in the appropriate boxes. To ensure specimen integrity, the CAP cannot deliver to a
PO box address, warehouse, or receiving dock.
D CAP Number
Current subscribers should verify the subscription number. If you are a new subscriber, a CAP number will be assigned to you. This number will appear on the Order Confirmation Report that will be mailed to you within three weeks of processing your order.
E Order Number; AR Number
These numbers are automatically assigned to your order form at the time of printing. They are used for internal tracking purposes.
F Payment Information
To ensure timely processing, please complete the “Payment Information” section. You are asked to indicate method of payment, purchase order number if applicable, credit card information including expiration date and authorized signature, and total dollar amount of the order.
Part 2 - Pre-Printed Order Form
G Current Product Enrollment Status
This information reflects the modules in which you were enrolled in 2001. To make changes to this order, use the “Delete or Change Quantity” column. If you wish to delete an item completely, please enter “0” in the “Revised Quantity” column.
H Tax Information
If you are subject to sales tax, the appropriate sales tax for your locale will be assessed and will be added to your invoice. Please include applicable sales tax with prepaid orders. If you are not subject to sales tax and have not notified the CAP, please enclose your tax-exempt certificate with your order form.
Part 3 - Product Addition Form
I New Products
To enroll in additional modules, please refer to the individual products listed in the program catalog and provide the following information on the Product Addition Form:
- Product code - e.g., HE for Basic Hematology
- Description (optional)
- Quantity - number of orders you want to receive (an order includes all shipments appropriate for the specific module)
- Price per product (optional)
- Extended price - cost of the module multiplied by the quantity ordered (optional)
If additional space is needed to order new products, you may copy the Product Addition Form, or contact Customer Service at 800-323-4040 option 1 # to obtain additional forms. Please return all pages of your order form.
Keep a copy of the complete order form for your records.