- CMS-116 CLIA Application
- Arizona Health Screening Registration Form
- Facility Change of Status Form
- Disclosure of Ownership and Control Interest Form
- Frequently Asked Questions
Questions concerning
applications may be directed to (602) 364-0726. Additional information
concerning the CMS/CLIA programs may be obtained at CLIA
CMS-116 CLIA Application
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. Checks should be made out to CLIA 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.
CMS-116 CLIA Application Form
Good Laboratory Practices for Waived Laboratories
Applications are not
complete until all forms are filled out and submitted.
Arizona Health Screening Registration Form
The registration 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.
Health Screening Registration Form
Applications are not complete until all forms are filled out and submitted.
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
Disclosure of Ownership and 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 and Control Interest Form
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