LCP FORM NO.

22 – 302
Department of Health
GENERAL INFORMATION SHEET
NATIONAL REFERENCE LABORATORY
Revision 06
Lung Center of the Philippines February 2019
Department of Pathology and Laboratory Page 1 of 1
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph
Telephone: 924-6101 loc. 4041 - 4043 E-mail: lcpnrlcc2007@gmail.com

_____ NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

1. Documents REQUIRED for Submission to LCP-NRL:

1.1. Original copy of LCP-NRL Documents: General Information Sheet
1.2. Order of Payment
1.3. Photocopy of the 2019 Laboratory LICENSE TO OPERATE
1.4. For bank to bank transaction: Machine validated transaction/deposit slip (affix Name of Laboratory)

GENERAL INFORMATION
Name of Clinical Laboratory (based on your Latest License to Operate)

Complete Address (No./ Unit/ Street/ Barangay/ City/ Province) Region

Laboratory E-mail Address: Telephone No. with Area Code or Contact Nos. Mobile No.

Head of Laboratory (Pathologist):

Contact Nos.

Check Appropriate Boxes: CLASSIFICATION BY OWNERSHIP

Primary Government Hospital-Based
Secondary Private Institution-Based
Tertiary Free-Standing
NEQAS Participation:
Initial/New Participant Renewal/Old Participant Year last Participated: __________

FOR Laboratory Staff only: (To receive the NRL Documents and NEQAS-CC Samples)
Name of Laboratory Staff Designation Mobile Number

1.

2.

3.
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
FOR LCP-NRL staff only:
Over the Counter O.R. No: _____________________ NRL CONTROL NO.
Mode of
Cash O.R. Date: _____________________ 2019 - _______________
Payment
Check Amount: _____________________ Date Received:
Bank to Bank Transaction: Date of deposit: _______________ _________________________
 Department of Health LCP FORM NO. 22 – 304
NATIONAL REFERENCE LABORATORY ORDER OF PAYMENT
Lung Center of the Philippines for NEQAS-CC PARTICIPATION
Department of Pathology and Laboratory Revision 06
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph February 2019
Telephone: 924-6101 loc. 4041 - 4043 E-mail: lcpnrlcc2007@gmail.com Page 1 of 1

_______ NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

LCP - NRL FILE COPY

Name of Clinical Laboratory: ____________________________________________________________________

(Refer on your Latest License to Operate- ACRONYMS NOT ALLOWED -unless specified)

Mode of Payment:
Cash Check Over the Counter Bank to Bank

For the Check payments only:

Bank: __________________________
Branch: __________________________ REMINDERS:
Check No.: __________________________
1. For bank to bank payment, Official Receipt shall
Date: __________________________ be delivered to the laboratory together with
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: the NEQAS-CC samples & its accompanying
documents.
FOR LCP-NRL staff only:
2. NEQAS-CC PARTICIPATION FEE is:
O.R. No.: _________________ Received by:
Amount : _________________ _________________ NON-REFUNDABLE, NON-TRANSFERABLE and
Date : _________________ Date : _____________ CANNOT BE USED as an ADVANCED PAYMENT
for the NEXT NEQAS-CC CYCLE.

Department of Health LCP FORM NO. 22 – 304

NATIONAL REFERENCE LABORATORY ORDER OF PAYMENT
Lung Center of the Philippines for NEQAS-CC PARTICIPATION
Department of Pathology and Laboratory Revision 06
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph February 2019
Telephone: 924-6101 loc. 4041 - 4043 E-mail: lcpnrlcc2007@gmail.com Page 1 of 1

_______ NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

LCP - CASHIER DIVISION

Name of Clinical Laboratory: ____________________________________________________________________

(Refer on your Latest License to Operate- ACRONYMS NOT ALLOWED -unless specified)

Mode of Payment:
Cash Check Over the Counter Bank to Bank

For the Check payments only: 2019 NEQAS-CC PARTICIPATION FEE:

Bank: __________________________
P 8,000.00*
Branch: __________________________
Check No.: __________________________
* NON-REFUNDABLE, NON-TRANSFERABLE and
Date: __________________________ cannot be used as an ADVANCED PAYMENT for the
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: NEXT NEQAS-CC CYCLE
Enclosed is our check payable to the
LUNG CENTER OF THE PHILIPPINES