Marin County BinaxNOW Antigen Testing Kit Agreement and Request Form
Testing requirements and details are available at
https://coronavirus.marinhhs.org/providers#test
* Required
Facility name:
*
Your answer
Facility type:
*
Choose
Hospital
Clinic (FQHC)
Clinic (private)
SNF
RCFE
Other Group Living
Private Practice
Urgent Care
Other
Primary point of contact (POC) name:
*
Your answer
POC title:
*
Your answer
POC email:
*
Your answer
POC phone number:
*
Your answer
The statements below are related to your facility's qualifications.
Does your facility have a Clinical Laboratory Improvement Amendments (CLIA) waiver?
*
Yes
No
Does your facility have staff trained to properly administer the tests?
*
Yes
No
Will your facility adhere to requirements to report test results to the California Department of Public Health (CDPH) using the CalREDIE Manual Lab Reporting Module (MLRM) within 8 hours of conducting the test?
*
Yes
No
Has your facility submitted your institutional protocol for utilizing BinaxNow, reflecting adherence and understanding to the guidance above? [Send protocol to MHOAC via email,
mhoac@marincounty.org
or fax, 415-473-3950.]
*
Yes
No
Test kits come in boxes of 40.
Number boxes requested:
*
Your answer
Current stock of kits:
*
Your answer
If LTCF, current census:
Your answer
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