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Laboratory Field Services

Forms


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State Forms

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

​​​​Out-of-State Forms​

 LAB 116 OS (PDF)​ ​- OOS Laboratory Personnel Report​
 LAB 167 OS (PDF) - OOS Annual Test Vol​ume of California Specimens​
 LAB 168 OS (PDF) - OOS Laboratory Personnel Qualification

Federal Forms

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

Related Links

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

Send to LFS

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​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.)
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