Follow the steps to complete the MD DoH Tissue Bank Application online.

1. Press the ‘Get Form’ button to access the MD DoH Tissue Bank Application form and open it in your preferred editor.
2. Begin by filling out the Tissue Bank Information section. Provide the laboratory practice or entity name, director's name, street address, city, state, zip code, email address, telephone number, and, if applicable, the mailing address. Indicate the tissue type and attach your State Permit Number if you have one.
3. Next, complete the Medical Director Information section. Input the medical director's name, degree, full-time or part-time status, certification details from the American Specialty Board, and state medical license number.
4. Fill out the Technical Director Information section similarly, providing the name and degree of the technical director, their status as full-time or part-time, and relevant certification details.
5. In the Ownership Information section, list the names and addresses of individuals or organizations that own or control over 5% of the entity. Provide their Federal Tax ID numbers as required.
6. Complete the Accreditation Information section by indicating if the laboratory is accredited by an approved organization. If so, provide the name of the organization and the date of the last on-site survey.
7. In the Tissue Types section, check all relevant tissue types associated with your bank and provide additional types if necessary. If applicable, indicate whether any laboratory testing is performed.
8. Move to the Attestation section and confirm the accuracy of the information provided by signing and dating the application.
9. Before submission, review the checklist to ensure all required documentation, including director credentials and signatures, are included. After completing the application, you may save changes, download, print, or share the form as needed.

Begin your application process online today and ensure you have all necessary documents ready for submission.