Lab 155 Form PDF Details

The State of California Health and Human Services Agency, through its California Department of Public Health, provides an essential tool for clinical laboratories to establish and maintain their operations legally within the state. This tool, known as the Lab 155 form, serves as an APPLICATION for CLINICAL LABORATORY REGISTRATION. It is a comprehensive document that requires detailed information about the laboratory applying for registration, including the name and address of the laboratory, its Tax ID number, telephone and fax numbers, email address, and the CLIA (Clinical Laboratory Improvement Amendments) provider number. Additionally, the form seeks information regarding the type of certificate needed, such as a Certificate of Waiver or Provider Performed Microscopic Procedures. It delves deeper into the operational structure of the laboratory by asking for details about the legal name of the corporation, type of ownership—whether individual, partnership, corporation, or unincorporated association—and specific information about directors or owners, including names and personal addresses. Importantly, the form requires the inclusion of the laboratory director(s), highlighting the need for oversight and management from qualified individuals, verifying their commitment through signatures. Fees associated with state registration are outlined, with specific instructions on making payments to the California Department of Public Health being provided. This meticulous process ensures that laboratories operating within California adhere to the state's high standards, promoting public health and safety through regulatory compliance.

QuestionAnswer
Form NameLab 155 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescalifornia clia waiver, lab155, lab 155 form, clia waiver application form

Form Preview Example

State of California—Health and Human Services Agency

California Department of Public Health

APPLICATION-- CLINICAL LABORATORY REGISTRATION

Refer to California Business and Professions Code, Division 2, Chapter 3

Instructions: Use typewriter or print in ink. Complete both pages of this application and return with required information and

fee to:California Department of Public Health

Laboratory Field Services /ATT: Clinical Laboratory Registration 850 Marina Bay Parkway, Bldg. P, 1st Floor

Richmond, CA 94804-6403

For application questions, e-mail. LFSRecep@cdph.ca.gov :

NOTE:State registration fees schedule: http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf

Make checks payable to: California Department of PUBLIC HEALTH

Items 1-3 MUST agree with the information for the CLIA Provider number and on the application for a Medi-Cal Provider number .

1. Name of laboratory

 

 

 

 

Tax ID number

 

 

 

 

 

 

 

 

 

Address (number, street)

 

 

City

County

State

ZIP code (include +4 digits)

 

 

 

 

 

 

 

 

Telephone number

Fax number

E-mail address

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

2.CLIA provider number

O5D ____ ____ ____ ____ ____ ____ ____

3. Type of certificate

Certificate of Waiver

Provider Performed Microscopic Procedure

4.Legal name of corporation, district, or association owning laboratory (fictitious name permit must be on file—state the name of locality where permit is filed)

5.Type of ownership. Check (Ｙ) and complete name and personal address (Section 1211 of Business and Professions Code).

Individual

Name

Personal address (number, street)

City

State

ZIP code

Partnership (general or limited). List name(s) and address(es) of all members of the partnership. Use supplementary sheet if necessary.

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Corporation. State names of officers, directors, shareholders holding a 5% or more interest in the corporation, and any person, partnership, or corporation who or which has the responsibility to manage or conduct the day-to-day operation of the laboratory. (Use supplementary sheet if necessary.)

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

Unincorporated association

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

LAB 155 (1/09)

Page 1 of 2

State of California—Healtlh and Human Services Agency

California Department of Public Health

District, city, county, or state

Name

Personal address (number, street)

City

State

ZIP code

 

 

Other (specify) (if nonprofit, submit proof of nonprofit status): ______________________________________________

Name

Personal address (number, street)

City

State

ZIP code

 

 

6. Laboratory Director(s) (M.D., D.O.)

 

 

 

 

 

Hours Per

 

 

 

 

 

Week

 

 

 

 

 

On-site

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

Name

Personal address (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

This statement must be signed by the owner, or a person legally authorized to bind the owner, and the laboratory director.

I declare that the foregoing statements are true and correct to the best of my knowledge and belief.

Laboratory Director signature (M.D., D.O.)

Type or print name

Title

Date

Owner signature

Type or print name

Title

Date

LAB 155 (1/09)

Page 2 of 2

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apply for clia in california writing process explained (stage 1)

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Part # 2 in completing apply for clia in california

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Completing part 3 of apply for clia in california

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Part no. 4 of filling out apply for clia in california

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