Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by filling in the current name of the laboratory and the State Lab ID number. Ensure these details are accurate as they identify your lab.
3. Next, input the Federal CLIA number and indicate whether this CLIA is a multisite. This information is critical for compliance and regulatory purposes.
4. Update the laboratory name if it has changed, and provide the date of the change.
5. List the owner's name along with the effective date of the change. Accuracy in this information helps in maintaining correct administrative records.
6. Enter the Tax ID number along with its date of change, ensuring that these fields reflect your laboratory's current tax information.
7. Fill in the director's name and date of change. Remember that a signature from the director is required for validation.
8. Complete the physical and mailing/billing address sections, providing the effective dates of these changes.
9. Update the telephone and fax numbers if there are any changes, along with the corresponding dates.
10. Indicate any specific tests being added or deleted, including the instrument/kit and manufacturer used for each test, as well as their effective dates.
11. Choose the appropriate change to the state license status and indicate if applicable dates are changing.
12. Select the change to the CLIA certification status, and remember to submit a CMS-116 if applicable. Note the respective change date.
13. Confirm if your office has closed or discontinued all clinical testing and provide the corresponding date.
14. Print the laboratory director’s name and obtain their signature along with the date to finalize the form.
15. Once you have completed all necessary fields, you can save changes, download the document, print it, or share it as needed.

Complete your MD DHMH Laboratory Licensing Change Form online today for efficient management of your laboratory licensing needs.