Lab 155 Form PDF Details

Have you recently been asked to fill out a Lab 155 form? Are you curious about what this form is, what information it will require from you, and why it’s necessary? Well, look no further! This blog post will provide the answers to all of your questions. Here, we’ll discuss the purpose of the lab 155 form, who’s required to complete it, when and where it must be completed—and more. So read on if you need some clarity regarding this important document before proceeding with its completion.

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

How to Edit Lab 155 Form Online for Free

You'll be able to fill out lab155 effectively by using our online PDF tool. To retain our editor on the leading edge of practicality, we work to put into action user-driven features and enhancements regularly. We're always pleased to get feedback - play a vital part in revampimg PDF editing. It just takes a couple of basic steps:

Step 1: Hit the orange "Get Form" button above. It is going to open our editor so you can start completing your form.

Step 2: Using our advanced PDF file editor, you are able to accomplish more than merely fill out blank form fields. Try all the features and make your documents seem great with custom textual content put in, or fine-tune the original content to excellence - all that supported by the capability to incorporate any type of graphics and sign the document off.

This PDF doc will require some specific details; in order to ensure consistency, don't hesitate to adhere to the subsequent tips:

1. To start off, while filling in the lab155, start out with the section that features the next blanks:

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

2. Right after this section is completed, go to enter the relevant information in these - Name, Name, Name, Personal address number street, Personal address number street, Personal address number street, City, City, City, State, ZIP code, State, ZIP code, State, and ZIP code.

Part # 2 in completing apply for clia in california

It is easy to make errors when filling out your State, so you'll want to go through it again before you'll finalize the form.

3. This 3rd segment should also be fairly simple, District city county or state, Name, Personal address number street, City, State, ZIP code, Other specify if nonprofit submit, Name, Personal address number street, City, State, ZIP code, Laboratory Directors MD DO, Hours Per, and Week Onsite - each one of these empty fields will have to be filled in here.

Completing part 3 of apply for clia in california

4. Completing Name, Personal address number street, City, State, ZIP code, This statement must be signed by, I declare that the foregoing, Laboratory Director signature MD DO, Type or print name, Owner signature, Type or print name, Title, Title, Date, and Date is key in this next stage - make certain that you take the time and fill out each and every blank!

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

Step 3: After you have looked once more at the details in the document, just click "Done" to complete your form. Right after creating afree trial account at FormsPal, you'll be able to download lab155 or email it right away. The PDF form will also be accessible from your personal account with your each and every edit. FormsPal is invested in the confidentiality of our users; we make certain that all personal data handled by our editor is confidential.

Lab 155 Form isn’t the one you’re looking for?

Related Documents