DOH 505-089 February 2016 Page 1 of 3 Qualifications of Personnel for Moderate Complexity Testing Director check only one FF 1. Medical Test Site MTS Credentialing P. O. Box 47877 Olympia WA 98504-7877 360-236-4700 Credential Status Change Form Use this form for address phone number fax number email or facility name or contact changes to individual credentials. Send the completed change form to the address listed above. Complete pages two and three only if you are changing the director of a categorized or accredited license. Your Information MTS Name Effective date of change MTS License Clinical Laboratory Improvement Amendments CLIA Type of Change to MTS Listed Above Address Change current address c Mailing c Physical c Both New Address City New phone enter 10 digit State Zip Code New fax enter 10 digit Facility Name change new name of MTS Name of new laboratory contact Email address Name of new microbiology contact Name of new cytology contact Do not complete pages two and three unle....
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How to fill out the WA Credential Status Change Form online
This guide provides clear instructions for users on how to accurately fill out the WA Credential Status Change Form online. Ensuring that your credentials are up-to-date is essential, and this step-by-step process will help simplify the task.
Follow the steps to complete the form correctly
- Click ‘Get Form’ button to access the WA Credential Status Change Form and open it in your preferred editor.
- Begin by entering your information in the designated fields. Input the name of your Medical Test Site (MTS), the effective date of the changes, and your MTS License Number. Also, include your Clinical Laboratory Improvement Amendments (CLIA) number if applicable.
- Indicate the type of change you are requesting by checking the appropriate box for an address change, phone number change, or facility name change. For address changes, specify if it is a mailing address, physical address, or both.
- Provide the new address information including street address, city, state, zip code, and new contact numbers. Make sure to enter the new phone and fax numbers as 10-digit numbers.
- If you are changing the facility name, write the new name of the MTS in the respective field. Also, list the contact information for any new laboratory personnel, including the names and email addresses of the new laboratory, microbiology, and cytology contacts.
- If applicable, fill out the sections related to the new laboratory director, including their name, license number, and email address. Remember to only complete the following fields if you are changing the director of a categorized or accredited license.
- For qualifications of personnel, select the appropriate options that apply to the new director’s qualifications. You may need to provide additional details about their experience and the laboratories where they have worked.
- As the final step, review all the information entered for accuracy. After confirming the details, you can save your changes, download the completed form, print it for mailing, or share it as directed.
Complete your WA Credential Status Change Form online today to ensure your credentials are accurately updated.
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