Follow the steps to complete your application accurately.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Provide your provider or licensee information. Input the clinical laboratory name, address, and telephone number as requested.
3. Enter your licensing information. Include AHCA Laboratory License # and CLIA # if applicable, alongside National Provider Identifier (NPI) and Medicare #.
4. Specify the type of licensee. Choose from 'For Profit', 'Not for Profit', or other applicable categories to identify your laboratory's ownership status.
5. Fill in your application fees based on the number of tests performed annually. Refer to the fee schedule outlined in the form to determine the correct amount.
6. Complete any required disclosures as specified. This includes reporting any convictions or exclusions related to Medicare or Medicaid.
7. Indicate whether your laboratory has any outstanding penalties, fines, or liens as required in the financial information section.
8. List the personnel involved in the laboratory operations, including the laboratory director and financial officer. Provide their licensing information and qualifications.
9. Detail the types and categories of tests performed, including non-waived tests and required quality assurance methodologies.
10. Finally, review and sign the affidavit section affirming the accuracy of the information provided before submitting the form along with all necessary attachments and fees.
11. After completing all sections, save the changes made, and ensure the form is either printed out, downloaded, or shared as required.

Complete your paperwork online and ensure accurate submission to streamline your licensing process.