TORY REGISTRATION NOTIFICATION TO ADD PERMANENT TESTING LOCATION TO A MULTI-SITE NETWORK APPLICATION INSTRUCTIONS E-mail: CLEPLtd health.ny.gov Web: www.wadsworth.org/regulatory/clep/limited-service-lab-certs This application is intended for use by not-for-profit and/or government Limited Service Laboratories in order to take advantage of a multisite Limited Service Laboratory Registration option, whereby you may link multiple permanent locations performing waived and/or providerperformed micro.
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How to fill out the NY DOH-4081MS online
Filling out the NY DOH-4081MS form is essential for not-for-profit and government limited service laboratories wishing to register and add a permanent testing location to a multi-site network. Below is a comprehensive guide to help you submit the form accurately online.
Follow the steps to complete the NY DOH-4081MS online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the first section, provide the primary laboratory information, including the legal name, address, and existing CLIA and PFI numbers if applicable.
- Complete the additional testing site information section for the new permanent testing location, including the testing site's name, county, address, and contact details.
- Indicate the testing site days and hours of operation, clarifying hours using AM/PM format.
- Select the type of laboratory from the given list that best describes your facility and enter the specific code in the application.
- Indicate whether the laboratory will perform community screening events and provide necessary protocols if applicable.
- For waived test procedures requested, check all tests you intend to perform and provide an estimated annual test volume for each.
- For provider-performed microscopy procedures requested, check all applicable procedures and estimate the annual test volume for these tests.
- Finally, complete the certification section by signing your name and providing the date, ensuring all information is accurate and compliant.
Start completing the NY DOH-4081MS online today to ensure compliance and facilitate your laboratory's operations.
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