Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the application and open it in your browser.
2. Provide the provider and licensee information in Section 1. Include the clinical laboratory name, address, and contact details. Ensure that the information is accurate as it will be publicly listed.
3. In Section 2, calculate and state the application fees based on your laboratory's test volume. Make sure to follow the provided fee schedule and prepare the payment accordingly.
4. Complete Section 3 regarding the controlling interests of the licensee. Input details for individuals or entities holding 5% or more ownership. Remember to avoid including social security numbers directly on this application; use the addendum for that information.
5. Answer all required disclosures in Section 5. This includes any past convictions or exclusions related to Medicare or Medicaid, which must be clearly explained.
6. Complete the Provider Fines and Financial Information section in Section 6. Include any outstanding fines or overpayments as necessary.
7. Indicate in Section 7 whether your facility participates in the Medicaid program, and ensure to submit a separate CLIA Application if applicable.
8. Fill in the type of laboratory and hours of operation in Section 8 and Section 9. Make sure the hours reflect actual operating times as this will affect site inspections.
9. Specify any collection stations or alternate testing sites in Section 10, if applicable. Include all necessary details about locations and tests performed.
10. For Section 11, state whether the laboratory is accredited, and if so, provide the name of the accrediting organization.
11. Provide personal and professional information for the director and financial officer in Section 12. Include relevant licenses and lab experience.
12. List all non-waived tests the lab will perform in Section 13. Ensure to clearly articulate the annual test volumes and accreditation programs associated.
13. Finally, sign the affidavit in Section 15, attesting to the accuracy of the information provided, and prepare to submit the completed application with any required attachments and payment.
14. After completing the form, save any changes made. Users can then download, print, or share the form as needed.

Complete your Health Care Licensing Application online today to ensure compliance and facilitate easier processing!