Get Nj Cl-4 2016-2025

This guide provides clear, step-by-step instructions for completing the New Jersey Clinical Laboratory License application form (NJ CL-4) online. Whether you are a healthcare administrator or a lab director, this comprehensive resource will help you navigate the process with ease.

Follow the steps to complete the NJ CL-4 application form online

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the laboratory information. Fill in the name of the laboratory, NJ CLIS ID number, laboratory address, and CLIA number in the designated fields.
3. Select the facility type from the provided options such as 'Physician Office Laboratory,' 'School,' or 'Home Health Agency.' Ensure that your selection accurately reflects the nature of your laboratory.
4. Include your mailing address where the licenses should be sent, along with the laboratory telephone and fax numbers.
5. Input the contact person's name and their contact telephone number. It is important to provide accurate information for any follow-up communication.
6. Indicate the normal hours of operation for the laboratory by specifying the hours for each day of the week.
7. Provide details for the laboratory director, including their name, state medical license number, degree, telephone number, and the time they are present on the premises.
8. Complete the primary general supervisor information section. Enter their name, degree, telephone number, and time on premises for each day of the week.
9. Fill in the ownership information, specifying the name of the owner or authorized agent, EIN federal tax ID, and address.
10. Choose the type of entity your laboratory represents, selecting from individual, partnership, corporation, non-profit, or government entity.
11. List the specific CLIA waived tests and NJ state waived tests performed in the laboratory. Include the name of the instrument or test kit, manufacturer, and the number of tests performed annually.
12. Indicate the total annual test volume and provide information about the proficiency testing provider(s).
13. Complete the attestation section. The laboratory director must sign and date the form, ensuring all information provided is accurate and complete.
14. Once all sections are accurately filled out, save your changes. You may download, print, or share the completed form as needed.

Start filling out your NJ CL-4 application form online today!