Doh 4081ms 2026

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4.1 out of 5

45 votes

The document is an application form from the New York State Department of Health for Limited Service Laboratory Registration, specifically for adding a permanent testing location to a multi-site network. It outlines the necessary information required from laboratories, including primary laboratory details, additional site information, waived test procedures, and provider-performed microscopy procedures. The form also includes a certification section where the applicant agrees to comply with health regulations and confirms the accuracy of the provided information.

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Click ‘Get Form’ to open the doh 4081ms in the editor.
Begin by filling out the 'Primary Laboratory Information' section. Enter your CLIA Number, Laboratory Name (up to 70 characters), PFI Number, and the physical address of your laboratory including city, state, telephone number, fax number, and ZIP code.
Proceed to the 'Additional Testing Site Information' section. Here, provide details for the new permanent testing location. Include the site name (limited to 70 characters), county/borough, physical address, contact person’s name and email address.
Indicate the days and hours when testing will be performed. Clearly specify AM/PM for each day of the week.
In the 'Waived Test Procedures Requested' section, check off all tests you intend to perform and indicate your estimated annual test volume.
Complete the 'Provider-Performed Microscopy Procedures Requested' section by checking all applicable procedures and providing estimated annual test volumes.
Finally, review and sign the certification section at the end of the form to attest that all information is accurate.

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Versions	Form popularity	Fillable & printable
2022	4.5 Satisfied (56 Votes)
2020	4.9 Satisfied (40 Votes)
2012	4.1 Satisfied (45 Votes)

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