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Click ‘Get Form’ to open the 0938 0581 2007 form in the editor.
Begin with Section I: General Information. Indicate whether this is an initial application, a change in certification type, or other changes. Fill in your CLIA Identification Number if applicable.
Complete the Federal Tax Identification Number, Facility Name, and contact details including telephone and fax numbers. Ensure the facility address is accurate as it will be used for correspondence.
In Section II, select the type of certificate requested by checking the appropriate box. Each option has specific requirements; ensure you understand which applies to your laboratory.
Proceed to Section III and select the type of laboratory that best describes your facility from the provided list.
For Section IV, list the hours during which laboratory testing is performed using HH:MM format for each day of the week.
If applying for multiple sites in Section V, indicate whether you meet regulatory exceptions and provide necessary details about each site.
Continue filling out Sections VI through X regarding testing volumes and director affiliations as required.
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