Form Cms-116 - Clinical Laboratory Improvement Amendments Of 1988 (Clia) Application For Certification
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9DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0581
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA)
APPLICATION FOR CERTIFICATION
I. GENERAL INFORMATION
CLIA IDENTIFICATION NUMBER
Initial Application
Survey
Change in Certificate Type
D
Closure/Other Changes (Specify)
(If an initial application leave blank, a number will be assigned)
Effective Date
FACILITY NAME
FEDERAL TAX IDENTIFICATION NUMBER
EMAIL ADDRESS
TELEPHONE NO.
FAX NO.
(Include area code)
(Include area code)
FACILITY ADDRESS —
MAILING/BILLING ADDRESS
Physical Location of Laboratory (Building, Floor, Suite
(If different from facility address) send Fee
if applicable.) Fee Coupon/Certificate will be mailed to this Address unless
Coupon or certificate
mailing or corporate address is specified
NUMBER, STREET
NUMBER, STREET
(No P.O. Boxes)
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
CORPORATE ADDRESS
SEND CERTIFICATE TO THIS ADDRESS
SEND FEE COUPON TO THIS ADDRESS
(If different from facility) send Fee Coupon or
certificate
Physical
Physical
NUMBER, STREET
Mailing
Mailing
Corporate
Corporate
NAME OF DIRECTOR
CITY
STATE
ZIP CODE
(Last, First, Middle Initial)
CREDENTIALS
FOR OFFICE USE ONLY
Date Received
II. TYPE OF CERTIFICATE REQUESTED
((Check only one) Please refer to the accompanying instructions for inspection and
certificate testing requirements)
Certificate of Waiver (Complete Sections I – VI and IX – X)
Certificate for Provider Performed Microscopy Procedures (PPM) (Complete Sections I – X)
Certificate of Compliance (Complete Sections I – X)
Certificate of Accreditation (Complete Sections I – X) and indicate which of the following organization(s) your
laboratory is accredited by for CLIA purposes, or for which you have applied for accreditation for CLIA purposes.
The Joint Commission
AOA
AABB
A2LA
CAP
COLA
ASHI
If you are applying for a Certificate of Accreditation, you must provide evidence of accreditation for your
laboratory by an approved accreditation organization as listed above for CLIA purposes or evidence of application
for such accreditation within 11 months after receipt of your Certificate of Registration.
NOTE: Laboratory directors performing non-waived testing (including PPM) must meet specific education,
training and experience under subpart M of the CLIA regulations. Proof of these qualifications for the laboratory
director must be submitted with this application.
Form CMS-116 (05/15)
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Parent category: Medical