Health ny professionalsemsNEW YORK STATE DEPARTMENT OF HEALTH LIMITED TESTING 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 - Primary Laboratory Information. Fill in the legal name and address of your Primary Limited Service Laboratory, along with the CLIA & PFI numbers if available.
3. Proceed to Section 2 - Additional Testing Site Information. Enter details for the new permanent testing location, including its name, county, address, and contact information.
4. In Section 3A, list all Waived test procedures you wish to perform at the new site. Provide estimated annual test volumes for each procedure.
5. Complete Section 3B by indicating any Provider-performed Microscopy (PPM) Procedures you plan to conduct and their estimated annual volumes.
6. Finally, ensure that Section 4 is signed by the Laboratory Director responsible for the testing. Remember that original signatures are required.

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