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Disclosure of Ownership and Control Interest Form - azdhs

Disclosure of Ownership and Control Interest Form - azdhs 2026

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The document provides detailed instructions for completing the Disclosure of Ownership and Control Interest Statement (Form -1513) specifically for CLIA laboratories. It outlines the necessary parts to be filled, definitions of ownership and control interests, and the importance of accurate and current information. The document emphasizes compliance with regulations to avoid potential suspension or revocation of CLIA certificates.

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Click ‘Get Form’ to open the Disclosure of Ownership and Control Interest Form in the editor.
Begin by filling out Item I, providing identifying information such as the name of the entity, DBA, address, EIN, and contact details.
Proceed to Item II and answer the questions by checking 'Yes' or 'No'. If any question is answered 'Yes', provide additional details in the Remarks section on page 2.
In Item III, list all individuals and organizations with direct or indirect ownership interests. Ensure you understand the definitions provided for clarity.
For Items IV-VII, indicate any changes in ownership or management control. If applicable, provide dates and additional information as required.
Review all entries for accuracy before saving your completed form. Utilize our platform's features to easily modify any sections if needed.

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