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.

Apr 1, 2020 · CMS 116 Dynamic List Information ... Form Title. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION. Revision Date. 2020-04-01. O.M.B. # 0938-0581. O.M.B. Expiration Date. 2024-03-31. Special Instructions. N/A. Downloads. CMS Form-116 (03/2024) Related Links. State Agency & …

Jun 7, 2024 · Complete the Application for Certification Form (CMS-116) (PDF), unless you're: A New York state non-physician office laboratory applicant. Email or call the New York State Department of Health at (518) 485-5378 for guidance. A Washington state applicant. Email or call the Washington State Agency at 253-395-6746 for guidance.

form cms-116 (04/20) 1 department of health and human services centers for medicare & medicaid services form approved omb no. 0938-0581. clinical laboratory improvement amendments (clia) application for certification all applicable sections of this form must be completed. i. general information initial application . anticipated start date . survey

Feb 14, 2025 · First, download the CMS-116 Clinical Laboratory Improvement Amendments (CLIA) application form (Form CMS-116, CLIA APPLICATION FOR CERTIFICATION). In section I of this CMS-116 form, complete the basic information regarding your laboratory and director.

Form 3225 is used as a supplement to the Centers for Medicare & Medicaid Services (CMS) Form CMS-116 (PDF) to apply for a Clinical Laboratory Improvement Amendments of 1988 (CLIA) program certificate.

The new fillable version of Form CMS-116 has been posted on the CLIA web page under "How to Apply for a CLIA Certificate, Including International Laboratories." The new version becomes effective on April 1, 2024, and expires on March 31, 2027.

The CLIA application (Form CMS-116) collects information about your laboratory’s operation which is necessary to determine the fees to be assessed, to establish baseline data and to fulfill the statutory requirements for CLIA.

The CLIAapplication (Form CMS­116) collects information about your laboratory’s operation which is necessary to determine the fees to be assessed, to establish baseline data and to fulfill the statutory requirements for CLIA.