Massachusetts General Hospital
CLIA & Accreditation Request Form
FORM INSTRUCTIONS:
Please return the completed form to cleuschen@partners.org / 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 Cliff Leuschen at (617) 724-0633.
MGH Use Only:
CLIA No ______________
Scanned: _____________
Database: _____________
Sent: _________________
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: or
MGH Non-Pathology. Samples sent for testing by MGH.
Please list the names of all tests performed 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:
and type of consult:
Other Reason:
3)
Previous MGH CLIA Certificate Number:
4)
YOUR staff requesting info :
5)
YOUR institution:
6)
YOUR street address:
7)
YOUR city
8)
YOUR phone number:
9)
YOUR e-mail
(if different from above)
10) Information Requested:
Please specify other:
Version 6.2 / Nov 2009
state
zip code:
AND fax:
CLIA Certificate
Accreditation
MGH Pathology Service
Other
Please type or copy this URL in your web browser to see the reference ranges:
http://labtest.partners.org/ReferenceRanges.htm
Please type or copy this URL in your web browser to see test pricing:
http://mghlabtest.partners.org/ResearchRates.htm
Please type or copy this URL in your web browser to see information on setting up a study:
http://mghlabtest.partners.org/Study.htm
MGH Department of Pathology, 55 Fruit Street, GRB-536, Clinical Laboratory Improvement
Amendments (CLIA) ID No. 22D0650226:

Blood Transfusion

Clinical Research Core

Core Laboratory:
o Chemistry
o Hematology
o Coagulation

Cytopathology

Diabetes

Histocompatibility

Histology

Immunology

Immunopathology

Microbiology

Molecular Diagnostics

Phlebotomy

Special Coagulation

Surgical Pathology
Version 6.2 / Nov 2009
MGH Pathology Service