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Get WA Credential Status Change Form 2012

Y name or laboratory contact changes to individual credentials. Please complete page two if you are changing a director of a categorized or accredited license. Send the completed change form to the address listed above. Your Information MTS Name Effective date of change MTS License # Clinical Laboratory Improvement Amendments (CLIA) # Type of Change to MTS Listed Above Address Change New Address City State Zip Code Phone and Fax number change Phone (enter 10 digit #) Fax (enter 10 digit #).

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