Quest Supply Order Form - Health Partners Plans

CLIENT SUPPLY ORDER FORM

Quest Diagnostics Incorporated 900 Buisness Center Drive Horsham, PA. 19044

CLIENT SUPPLY CALL CENTER.......................... 866-344-5178 CLIENT SUPPLY FAX NUMBER ....................... 800-522-4601 Please allow 3-5 buisness days for delivery

Client Number

Date Contact/Client Name Address

Phone Number E-mail

Qnty Ordr'd

Units

*PK/100 *PK/100 EACH EACH EACH EACH EACH EACH EACH EACH EACH *PK/100 *PK/100

*PK/100 EACH *PK/100 EACH

BX/48 BX/48 EACH

EACH EACH EACH

ID

Description

BLOOD COLLECTION TUBES T47 Serum Separator Tube T04 Lavender Top Tube - EDTA T62 Lavender Top Tube - 10ml T09 Red Top Tube - Plain/No Preservative T07 Blue Top Tubes - Sodium Citrate T11 Tan Top Tube (Hemogard) T88 Gray Top Tube (Sodium Floride/Potassium Oxalate) T11 Navy Blue Top Tube - EDTA T13 Navy Blue No Additive T24 Yellow-Top ACD Solution B T05 Green Top Sodium Heparin S08 Transfer Tubes (Select Cap Below) A37 Purple Caps (Plasma)

PEDIATRIC BLOOD COLLECTION TUBES T26 Serum Separator Tube T10 Red Top Tube - Plain/No Preservative T30 Blue Top Tubes - Sodium Citrate T43 Gray Top Tube (Sodium Floride/Potassium Oxalate)

NEEDLES N14 Needles, Multidraw 21 G 1 1/4" Safety N13 Needles, Multidraw 22G 1 1/4" Safety N07 Needle Holders (single use)

BLOOD CULTURES C06 Bactec, Aerobic Blood Culture Bottle C07 Lytic, Anerobic Blood Culture Bottle C08 Bactec, Pediatric Blood Culture Bottle

Item

Qnty

num

Ordr'd

7.5ml 170739 4ml 141997 10ml 159861 10ml 53712

4.5ml 38417 3ml 141847 4ml 141882 6ml 38416 7ml 38427 6ml 53725 10ml 180824 49867 134480

3.5ml 130058 3ml 141912

2.7ml 141876 3ml 38431

141999 141994 151539

56471 141845 56308 OTHER ITEMS :

Units

EACH EACH EACH EACH EACH EACH *PK/10 *PK/10 EACH EACH EACH EACH EACH EACH EACH EACH

EACH *PK/25 EACH EACH *PK/100 EACH *BG/5 EACH

ID

Description

TRANSPORTATION MEDIA

C01 Culture Swab, Copan Blue Gel Aero/Ana

M10 Virapap Kits (HPV)

M30 VCM Viral Culture Green Legion/Skin/Other

M31 VCM Viral Culture Green Nasopharygeal

M32 VCM Viral Culture Green Female/Cervical

M33 VCM Viral Culture Green Male/Urethral

F04 InSure Fecal Immuno

M01 Affirm Vaginosis Testing

F02 Parasitology, Kit, Total Fix

F01 Stool C&S Transport Media

U05 Stool Container White 8oz

U14 Sputum Collection Container

M04 Aptima, sureswab

M03 Aptima, Probe Male/Female Combo

M02 Aptima, Urine Male/Female Combo

A03 Urea Breath Tech Kit

URINE COLLECTION

U36 Pain Management Cups

U13 Urinalysis Vial w/ Preservative 10ml

U11 4 oz Sterile Container

4oz

C11 Urine C&S Kit Plastic

5ml

U15 Urine Collection Cups (Uricups)

U01 24Hr Urine Container (Select Preservative Below)

A17 Boric Acid (use 4 tab/24hr container)

U29 6N HCL (25ml)

Item num

141902 3113 142060 142059 142057 142058 129031 141900 170511 141856 168680 127553 141905 141880 141879 155155

154873 134626 170551 141974 177111 156874 101533 159972

Qnty Ordr'd

Units ID

Description

CYTOLOGY AND HISTOLOGY COLLECTION

EACH A32 Prostate Biopsy Kit pk14

EACH A35 Prostate Biopsy Kit pk 8

EACH A34 Bone Marrow Biopsy Kit

EACH U07 Biopsy Bottle w/ Formalin 60ml

EACH U45 Biopsy Bottle w/ Formalin 120ml

EACH U26 Biopsy Bottle w/ Formalin 20ml

EACH P16 Cytology Solution

30ml

*PK/25 P04 Kit, ThinPrep Coll Vial w Brooms

*PK/25 P03 Kit, ThinPrep Coll Vial w Brush/Spatula

*PK/25 P15 SurePath Kit Vial w Brooms

*PK/25 P14 SurePath Kit Vial w Brush & Spatula

*PK/25 P13 SurePath Brooms Only

*PK/25 P12 SurePath Brushes/Spatulas Only

MISCELLANEOUS

EACH G01 Glucose, Orange 50GM

EACH G10 Glucose, Lemon lime 75GM

EACH G11 Glucose, Fruit Punch 100GM

*500/PK R79 Paper w/o Logo 8 ? x 11 Green Stripe

*500/PK R09 Printer Paper w/ Quest Logo_ 8 ? x 11

*100/PK B01 Specimen Bags Routine

*100/PK B25 Specimen Bags (Electronic )

EACH

Toner(Please Specify name & model #)

EACH

Drum (Please Specify name & model #)

ROLL

R07 Labels Dymo/CC Link

REQUISTIONS - Please Specify

Item num

141881 165640 143878 135749 135751 165943 48880 141767 141768 165886 165885 141917 141918

141928 141933 158822 153296 141849 142696 142689142689

56987

8/12/2016

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