Get Application For Renewal Clinical Laboratory License. Lab 144r - Cdph Ca

This guide provides clear and detailed instructions on how to complete the Application For Renewal Clinical Laboratory License. LAB 144R - Cdph Ca online. By following these steps, you can ensure that your application is submitted accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by choosing one of the following options: either register for state oversight or select deemed status with an accrediting organization approved by the California Department of Public Health, such as CAP, COLA, or The Joint Commission. If you opt for deemed status, include a copy of your current certificate of accreditation or a letter of acknowledgment from the accrediting organization.
3. Fill in the laboratory's name, tax ID number, address (including number, street, suite/apartment), city, county, state, and zip code along with your contact information, including telephone and fax numbers, and email address.
4. Provide the CLIA provider number and the number of testing sites affiliated with this CLIA number. If there are multiple sites, be prepared to complete form B.
5. Indicate the legal name of the corporation, district, or association owning the laboratory. Ensure that a fictitious name permit is on file and provide the name of the locality where it is filed.
6. Select the type of ownership for the laboratory by checking the appropriate box and completing the corresponding name and address information. Options include individual, partnership, corporation, unincorporated association, district, city, county, or state. If nonprofit, please submit proof of nonprofit status.
7. List the laboratory director(s), including their names and addresses. Ensure to note the hours they are on-site per week.
8. Complete the statement requiring signatures from both the owner or a legally authorized person and the laboratory director, ensuring that the declarations made are true and correct.
9. Review all the information filled out in the application to ensure it is accurate and complete.
10. Once finished, save changes to your form. You may also download, print, or share the completed form as needed.

Start completing your Application For Renewal Clinical Laboratory License online today.