Are you looking for the appropriate forms to begin your process of obtaining a professional lab license in Maryland? Obtaining the necessary licensing for a laboratory can seem daunting, but with the right guidance and understanding it doesn't have to be. This post provides an overview of how to obtain a Maryland Lab License through filing out different requisite forms. Relevant information regarding specific forms, requirements needed when filing, as well as other useful tips are also provided throughout in order to aid any individual or business needing this type of certification.
| Question | Answer |
|---|---|
| Form Name | Maryland Laboratory Licensing Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | laboratory change form pdf, maryland laboratory change form, maryland laboratory permit change form, clia waiver maryland |
Maryland Department of Health and Mental Hygiene |
Office Use Only |
55 Wade Avenue, Catonsville, MD 21228 Amount:
Phone: 410.402.8025 Fax: 410.402.8213 Date Completed:
Laboratory Licensing Change Form
This form is for changes and updates only. Please only provide us with the changes in the fields below along with the effective date of the change.
For a change of Director, a copy of the Director’s medical license, medical diploma and board certification must be submitted. Please send diploma and CV for a PhD Director. This form must be signed by the Director for these changes to be valid.
***THIS FORM MUST BE SIGNED BY THE DIRECTOR FOR ALL CHANGES TO BE VALID.***
Please return this form by fax:
Or by mail:
Attention: Lab Licensing, OHCQ – Bland Bryant Building,
55 Wade Avenue, 1st Floor, Catonsville, MD 21228
Current Name of Lab: ___________________________
State Lab ID # __________ Federal CLIA #: ___________ Is this CLIA a multisite? Y N
Laboratory Name: |
________________________________ |
Date of Change: ___________ |
Owner: |
________________________________ |
Date of Change: ___________ |
Tax ID #: |
________________________________ |
Date of Change: ___________ |
Director: |
________________________________ |
Date of Change: ___________ |
Physical Address: |
________________________________ |
Date of Change: ___________ |
|
________________________________ |
|
Mailing/Billing Address: _____________________________ |
Date of Change: ___________ |
|
|
_____________________________ |
|
Telephone #: |
________________________________ |
Date of Change: ___________ |
Fax #: |
________________________________ |
Date of Change: _________ |
2
Please list the tests you are adding or deleting from your current test menu. Please use the chart below and indicate for each test the instrument/kit used as well as the effective date of change.
|
|
Changes/Additions/Deletions to Tests |
|
||
Test Name |
|
Kit/Instrument Used |
Add Delete |
Date of Change |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
______________ |
|
___________________ |
|
_____________ |
|
Change State License Status to: |
|
|
|
||
Letter of Exception |
General Permit |
Date of Change: ____________ |
|||
Change my CLIA Certification Status to: (must submit with a |
|
||||
Waiver |
Compliance |
Provider Performed Microscopic Procedures (PPMP) |
|||
Accreditation with which program? ____________________________________________
Date of Change: _________________________
____________________________________________________________________________
Our office has closed and/or discontinued all clinical testing. Date of Change: __________
Print Laboratory Director’s Name: ________________________________________________
Laboratory Director’s Signature: _______________________________ Date: _____________