Clia disclosure of ownership form texas 2026

1. Click ‘Get Form’ to open the CLIA Disclosure of Ownership Form in our editor.
2. Begin by filling out the Identifying Information section. Enter the name of your entity, doing business as (D/B/A), address, city, CLIA number, taxpayer ID number (EIN), state, ZIP code, and telephone number.
3. Proceed to Section II. Answer the questions regarding ownership and control interest by checking 'Yes' or 'No'. If you answer 'Yes' to any question, provide additional details in the Remarks section on page 2.
4. In Section III, list names and addresses for individuals or EINs for organizations with direct or indirect ownership. Specify the type of entity and include any relevant information about other Medicare/Medicaid facilities.
5. Complete Sections IV through VII by answering questions related to changes in ownership, management affiliations, and operational status. Ensure all responses are accurate to avoid potential legal issues.
6. Finally, review your entries for accuracy before signing and dating the form at the bottom. Use our platform's features to save or share your completed document easily.

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