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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

 LAB 116 (pdf) ​- Laboratory Personnel Report
 LAB 144 (pdf) - ​Initial Application (License)
 LAB 144A (pdf) ​- Laboratory Testing Declaration
  LAB 144B (pdf) ​- Application for Additional Testing Site
 LAB 144R (pdf) ​- Application to Renew (License)
 LAB 155 (pdf) ​- Initial Application (Registration)
 LAB 155R (pdf) ​- Application to Renew (Registration)
 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


Federal Forms

 CMS 116 (pdf) ​- CLIA Application for Certification
 CMS 209 (pdf) ​- CLIA Laboratory Personnel Report

Related Links

 Payment Request Sheet (pdf) ​- Mail-in payment request for an online application

Send to LFS

mailit

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

emailit

​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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​Upload Online:                     
Upload the completed and signed forms in your application.

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