Medical application 2026

1. Click ‘Get Form’ to open the CHDP Laboratory Provider Application in the editor.
2. Begin by filling in your laboratory's legal name and provider number(s) as required. Ensure that this information matches your IRS records.
3. Provide your state laboratory license/registration number and, if applicable, your fictitious business name along with the necessary documentation.
4. Complete the business address section accurately, including street number, city, and ZIP code. Avoid using a P.O. Box.
5. Enter your primary business telephone number and fax number. Make sure these are active lines for communication.
6. Fill in the email address for electronic communications and specify the pay-to name for billing purposes.
7. Attach copies of required documents such as your CLIA certificate and FEIN verification before submitting the application.
8. Finally, ensure that both the Laboratory Director and Owner sign the application in blue ink, then submit it to the specified address.

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