1.
Waived or
PPMP Applications
2. Accreditation or Compliance Applications
3. Facility Change of Status Form
4. Disclosure of Ownership or Control Interest Form
5. Frequently Asked Questions
Questions concerning
applications may be directed to (602) 364-0726. Additional information
concerning the CMS/CLIA programs may be obtained at www.cms.hhs.gov/CLIA
Waived
or PPMP Application
Facilities requesting
waived or PPMP application will need to complete all portions of the application provided in
the link below. The application should be completed and sent to the Office
of Laboratory Services, ATTN: CLIA, 250 N. 17th Avenue, Phoenix, AZ 85007 OR
Faxed to (602) 364-0759.
Once the application has
been received and processed, an invoice will be generated from CMS Lab
Program. Checks should be made out to CMS Laboratory Program
and should include the CLIA number on the check to ensure that the
payment is accredited to the correct account. Do not send payments to
the state.
Certificate of Waiver or
Certificate of PPMP [PDF 5M]
Good Laboratory Practices
for Waived Laboratories
Applications are not
complete until all forms are filled out and submitted.
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Accreditation or
Compliance Application
Facilities requesting an
accreditation or compliance application will need to complete all portions of the
application
provided in the link below. The application should be completed and
sent to the Office of Laboratory Services, ATTN: CLIA, 250 N. 17th Avenue, Phoenix, AZ
85007 OR Faxed to (602) 364-0759.
Once the application has
been received and processed, an invoice will be generated from CMS Lab
Program. Checks should be made out to CMS Laboratory Program
and should include the CLIA number on the check to ensure that the
payment is accredited to the correct account. Do not send payments to
the state.
Certificate of Compliance
or Certificate of Accreditation [PDF 7M]
Applications are not
complete until all forms are filled out and submitted.
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Facility
Change of Status
Facilities
that have a change in status must complete the following form and fax it to the Office of Laboratory Services at (602) 364-0759.
Facility
Status Changes Form [PDF 262K]
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Disclosure
of Ownership or Control Interest
Facilities
that have a change in ownership must complete the following form and fax it to the Office of Laboratory Services at (602) 364-0759.
Disclosure
of Ownership or Control Interest Form [PDF 262K]
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