Change Of Status Form

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Bureau of Laboratories
PO Box 500
Exton PA 19341-0500
Phone: 610-280-3464
Change of Status Form
This form is for changes and updates only. Please only provide the Bureau with information that is changing
in the fields below along with the effective date of the change. Note that the name of the laboratory cannot
exceed 32 characters including spaces so make any necessary abbreviations.
Changes will be made to both state permit and CLIA certificates (if applicable).
In order for the Department to qualify a director a copy of the curriculum vitae (CV) and medical license must be
enclosed. For the Department to qualify a director as a moderate or high complexity director under CLIA, additional
documents are required. Please include a copy of any board certifications and a copy of any CEUs (continuing educational
units).
State Lab ID #
(required)
Federal CLIA # 39D
(required)
Is this Clinical Laboratory Improvement Amendments number (CLIA) a multisite laboratory? Y N
Are you reopening a laboratory that was previously closed less than 6 months? Y N
***
Laboratory Name:
_______________________________________ ______
Effective Date: ______________
Owner:
_____________________________________________
Effective Date: ______________
Tax ID #:
_____________________________________________
Effective Date: ______________
Director:
_______________________________________ ______
Effective Date: ______________
Dr.’s Medical License: _____________________________________________
Effective Date: ______________
Physical Address:
_____________________________________________
Effective Date: ______________
_____________________________________________
Mailing Address:
_____________________________________________
Effective Date: ______________
_____________________________________________
Billing Address:
_____________________________________________
Effective Date: ______________
_____________________________________________
Telephone Number:
_____________________________________________
Effective Date: ______________
Fax Number:
_____________________________________________
Effective Date: ______________
Contact Name:
_____________________________________________
Effective Date: ______________
Contact Phone #:
_____________________________________________
Effective Date: ______________
Contact Email Address: _____________________________________________
Effective Date: ______________
Change my state Clinical Laboratory Permit to:
Physician’s Office or Clinic
Hospital
Independent
Nursing Home
Mobile Lab
Screening Site
Effective Date: _____________

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