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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
ā€‹ LAB 144 (pdf) - ā€‹Initial Application (License)
ā€‹  LAB 144A (pdf) ā€‹- Laboratory Testing Declaration
 ā€‹ LAB 144B (pdf) ā€‹- Application for Additional Testing Site
ā€‹  LAB 144R (pdf) ā€‹- Application to Renew (License)
ā€‹  LAB 155 (pdf) ā€‹- Initial Application (Registration)
ā€‹  LAB 155R (pdf) ā€‹- Application to Renew (Registration)
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

Federal Forms

 ā€‹CMS 116 (pdf) ā€‹- CLIA Application for Certification
 ā€‹CMS 209 (pdf) ā€‹- CLIA Laboratory Personnel Report

Related Links

 ā€‹Payment Request Sheet (pdf) ā€‹- Mail-in payment request for an online application

Send to LFS

ā€‹mailit

ā€‹Mail to:
California Department of Public Health
Laboratory Field Services
850 Marina Bay Parkway
Bldg. P, 1st Floor
Richmond, CA  94804-6403
ā€‹emailit

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€‹uploadit

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

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