Skip Navigation LinksSubmitLabChanges

LABORATORY FIELD SERVICES​

 Back

Submit Changes


You must submit a request for change by email if you are not renewing. See requirements below.



Laboratory Director Change

There are no additional fees for Laboratory Director changes effective on or after April 1, 2020.

Form Requirements:

  • LAB 193 (PDF)- Notification of Laboratory Change
  • LAB 183 (PDF)- Director Attestation
  • CMS 116 (PDF)- to update CLIA certificate

We will contact you by email if additional information is required upon review. Be sure to include a valid email address on each form to avoid delay. See "Send Application To" below.​​


Ownership Change

There are no additional fees for ownership changes  effective on or after April 1, 2020.

Form Requirements:

  • LAB 193 (PDF) - Notification of Laboratory Change
  • LAB 183 (PDF) - Director Attestation
  • CMS 116 (PDF) - to update CLIA certificate
  • LAB 1513 (PDF) - Disclosure of Ownership (required for moderate/high complexity labs)

We will contact you by email if additional information is required upon review. Be sure to include a valid email address on each form to avoid delay. See "Send Application To" below.


Other Changes

  • Basic Changes

Basic changes such as address, phone, fax, contact person, email, laboratory name (without ownership change), certificate corrections, and laboratory closure, require these forms:

    • LAB 193 (PDF) - Notification of Laboratory Change
    • CMS 116 (PDF) - to update CLIA certificate



We will contact you by email if additional information is required upon review. Be sure to include a valid email address on each form to avoid delay. ​​​​​​



Send Application To...

email

Email a scanned copy of the forms  or any questions to:

LFScc@cdph.ca.gov

Page Last Updated :