Get Clia Ownership Information Form - Dhhs Ne
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CLIA Ownership Information Form - Dhhs Ne online
Filling out the CLIA Ownership Information Form is an essential step for laboratories operating in Nebraska. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.
Follow the steps to complete the CLIA Ownership Information Form online.
- Click ‘Get Form’ button to access the CLIA Ownership Information Form. This action will allow you to open the document and start filling it out.
- In the 'Laboratory Name' field, enter the name of the laboratory for which you are submitting ownership information.
- If applicable, input the CLIA Number for the laboratory. Note that this field is not required for initial applications.
- In the 'Ownership of Laboratory' section, provide the legal name of the individual or business organization that owns the laboratory.
- Fill in the 'Owner Address' field with the complete address of the owner.
- Enter the 'Federal Tax ID Number' associated with the laboratory's ownership.
- Select the type of business organization from the provided options: Sole Proprietorship, Partnership, Limited Partnership, Corporation, Limited Liability Company, or Governmental (State, District, County, City, or Municipal).
- Indicate whether the organization is Profit or Non-profit by checking the appropriate box.
- In the 'Name of Authorized Representative' field, print the name of the individual authorized to represent the laboratory.
- Provide the title of the authorized representative in the specified field.
- Ensure that the authorized representative signs the form in the 'Signature' section.
- If there are multiple owners, specify which owner is preferred as only one owner can be recorded in the system.
- If you have any additional comments or notes, you may include them in the 'Remarks' section.
- Once you have completed the form and reviewed it for accuracy, you can save your changes, download a copy, print the form, or share it as needed.
Ensure your laboratory's compliance by completing the CLIA Ownership Information Form online today.
Clinical Laboratory Improvement Amendments NOTE: Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing authority to promulgate standards for certain laboratory testing to ensure the accuracy, reliability and timeliness of test results regardless of where or by whom the test was performed. How to obtain a CLIA Certificate - CMS Centers for Medicare & Medicaid Services | CMS (.gov) https://.cms.gov › clia › downloads › howobt... Centers for Medicare & Medicaid Services | CMS (.gov) https://.cms.gov › clia › downloads › howobt... PDF
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.