Lab 155 2025

1. Click ‘Get Form’ to open lab 155 in the editor.
2. Begin by filling out the laboratory name, tax ID number, and address in the first section. Ensure that this information matches your CLIA Provider number.
3. In the next fields, provide your city, telephone number, fax number, and email address. Double-check for accuracy to avoid processing delays.
4. Select the type of certificate you are applying for from the options provided. This is crucial for determining your laboratory's compliance requirements.
5. Complete the ownership section by checking the appropriate box and providing names and addresses as required. If you have multiple owners or partners, use a supplementary sheet if necessary.
6. List all laboratory directors along with their on-site hours per week. Ensure that each director's personal address is included.
7. Finally, sign and date the form where indicated. Both the laboratory director and owner must provide their signatures to validate the application.

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