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Get WA Credential Status Change Form 2020-2024

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 unless you are changing the director of a categorized or accredited license. Pathologist with state license. FF 2. MD DO DPM with state license and 1 year directing or supervising non-waived testing. Which laboratory Dates Which program Dates FF 5. PhD in science and board certification ABB ABMM ABCC ABMLI. FF 7. Master Degree in science 1 year laboratory training and/or experience and 1 year laboratory supervisory experience. FF 8. Bachelor Degree in science 2 years laboratory training and/or experience and 2 years laboratory supervisory experience. FF 9. On 2/28/92 serving as laboratory director and qualified or could have qualified as director under previous Medicare/CLIA independent laboratory personnel requirements. FF 10. On 2/28/92 was qualified under state law to direct a laboratory. Complete the following information about the qualifications of your Clinical Consultant for Directors who are not qualified according to 1 through 4 above. Clinical Consultant check only one Signature of Director I certify that the information included on this form is accurate Signature of the Medical Test Site Director Date mm/dd/yyyy laboratory and have 2 years laboratory training and/or experience and 2 years directing or supervising high-complexity testing. FF 8. For subspecialty of oral pathology be certified by the American Board of Oral Pathology American Board of Pathology or American Osteopathic Board of Pathology or equivalent. 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. 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 unless you are changing the director of a categorized or accredited license.

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