Skip Navigation LinksFacilitiesForms

Top Menu
Left Menu

Laboratory Field Services

Forms

Download forms using the links below. Clicking a link will open another tab in your browser. You can also download by right-clicking the link and choosing "Save."

State Forms

ā€‹ LAB 116  (PDF) ā€‹- Laboratory Personnel Report
 LAB 144A  (PDF) ā€‹- Laboratory Testing Declaration
ā€‹ LAB 144B (PDF) ā€‹- Application for Additional Testing Site
ā€‹  LAB 167 (PDF) ā€‹- Annual Test Volume
ā€‹  LAB 182 (PDF) ā€‹- Owner's Attestation
ā€‹  LAB 183 (PDF) ā€‹- Laboratory Director's Attestation
ā€‹  LAB 193 (PDF) ā€‹- Notification of Laboratory Change
ā€‹  LAB 1513 (PDF)
 ā€‹- Disclosure of Ownership and Control Interest Statement

ā€‹ā€‹ā€‹ā€‹Out-of-State Formsā€‹

ā€‹ LAB 116 OS (PDF)ā€‹ ā€‹- OOS Laboratory Personnel Reportā€‹
ā€‹ LAB 167 OS (PDF) - OOS Annual Test Volā€‹ume of California Specimensā€‹
 LAB 168 OS (PDF) - OOS Laboratory Personnel Qualification

Federal Forms

CMS 116 (PDF)
 ā€‹- CLIA Application for Certification  || Link: Quick Start Guide (PDF)
CMS 209 (PDF) ā€‹- CLIA Laboratory Personnel Report

Related Links

Payment Request Sheet (PDF) ā€‹- Mail-in payment request for an online application
ā€‹LAB 163 (PDF)
 ā€‹- Complaint Information Form

Send to LFS

ā€‹at sign

ā€‹Email to:
LFScc@cdph.ca.gov

  • Subject line: Include any reference such as State ID, CLIA ID, application ID, and facility name.
  • Body of email: Include information such as type of application (initial, renewal, changes, etc.)
ā€‹computer with cursor

ā€‹Upload Online:                     
Upload the completed and signed forms in your application. ā€‹
ā€‹
ā€‹ā€‹
Page Last Updated :