Change-Request-Form-AAB-MLE - Billing and program module additions/deletions

Aug 26, 2026

AAB-MLE change-request form for updating billing and program enrollment details. The form collects account identifiers, event year, signature, and date, and requests new billing address and CLIA number, along with shipping address and contact information for kit delivery. It supports additions and deletions of complete program modules, specifies timing requirements (at least four weeks before ship date), and instructs users to use the test menu deletion form when analytes are no longer tested. Contact options include fax, phone, and email.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Change Request Instructions

Required Fields and Signature

Billing Updates and CLIA Number

Shipping Address and Contacts

Program Module Additions and Deletions

Additions

Deletions

Order Changes Timing and Requirements

Regulatory and Distribution Options

(REQUIRED)AAB-MLE\#-enter your Account/ID Number: (REQUIRED-fillin year &event)Make these change(s)for 20 (REQUIRED) Signature: Print Name: Date: Fax this form to 1-202-835-0440 NEW Billing Address-Address where the invoice will be sent NEW CLIA Number:D or email it to:mle@aab-m|e.org Phone: # Program Module\#Additions: Please Do NOT Send Form Unless You Have Changes.ONLY fill in the fields that changed. Choose Event(s)□M1 NEW Shippina Address-Address where the kits will be shipped (This address mav NOT be a PO Box) Contact/Facility Name: Address: Fax: Email: Contact/Facility Name: Address: Phone: Fax: Email: NEW Laboratory Director: Order Changes-List any program module \#s that you wish to add to-or delete from-your order.List ONLY complete program module additions or deletions.Do NOT list analytes.Order changes mustbe received at least four weeks before the corresponding ship date to avoid extra charges and fees. # Program Module\#Deletions: | Please report any individual analytes your laboratory is no longer testing by faxing or emailing the
Test Menu Deletion Form.It is not necessary to send both this form and the test menu deletion form;
we willadjust your test menu based upon your order changes.In most cases,deleting an analyte
from your test menu will not affect your program module order.
Questions?Call AAB-MLE Customer Service at 1-800-234-5315,or email:mle@aab-mle.org | | --- | Regulatory Agencies □ADD □DELETEID\#Assigned By Agency Additional Copies □ADD □DELETEName: Address: Ph Fax Fmail □The person named above is a consultant Please send me an updated Order Verification

FAQs

When should order change requests be submitted to avoid extra charges?

Order changes must be received at least four weeks before the corresponding ship date to avoid extra charges and fees.

What information is required for billing and account updates?

The form requires the account/ID number, the fill-in year and event, signature, printed name, date, and new billing address and new CLIA number.

How should program module changes be reported?

List only complete program module additions or deletions, not individual analytes, and use the provided additions/deletions sections for the module numbers.

Aug 26, 2026

Uploaded by Emma Mercer