Address and Laboratory Contact Change Form 505-087 - doh wa 2026

1. Click ‘Get Form’ to open the Address and Laboratory Contact Change Form 505-087 in the editor.
2. Begin by entering your Medical Test Site (MTS) name and the effective date of the change. Ensure that you also include your MTS License number and Clinical Laboratory Improvement Amendments (CLIA) number.
3. Select the type of change you are making: address, phone/fax number, facility name, or laboratory contact changes. Fill in the new address details including city, state, and zip code if applicable.
4. For phone and fax number changes, enter the new 10-digit numbers in their respective fields. If changing the facility name or laboratory contacts, provide the new names and email addresses as required.
5. Complete the qualifications section for personnel involved in moderate or high complexity testing by checking the appropriate boxes and providing necessary details about their qualifications.
6. Finally, ensure that the form is signed by the Medical Test Site Director along with the date before submitting it to the specified address.

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