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CMS-116 2015 free printable template

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Proof of these qualifications for the laboratory director must be submitted with this application. Form CMS-116 05/15 III. The CLIA application Form CMS-116 collects information about your laboratory s operation which is necessary to determine the fees to be assessed to establish baseline data and to fulfill the statutory requirements for CLIA. THE CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CLIA APPLICATION FORM CMS-116 INSTRUCTIONS FOR COMPLETION CLIA requires every facility that tests human...
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How to fill out CMS-116

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How to fill out CMS-116

01
Obtain the CMS-116 form from the official CMS website or your local CMS office.
02
Fill out the 'Provider Information' section with the required details such as name, address, and contact information.
03
Complete the 'Provider Type' section by selecting the appropriate options based on your services.
04
In the 'Request for Enrollment' section, indicate whether you are a new applicant or an existing provider updating your information.
05
Provide information regarding any prior Medicare or Medicaid enrollments in the 'Prior Enrollment Information' section.
06
Attach any necessary supporting documents, such as licenses, certifications, and identification.
07
Review the form for completeness and accuracy before signing and dating it.
08
Submit the completed form to your local CMS office by mail or electronically, if applicable.

Who needs CMS-116?

01
Healthcare providers seeking to enroll in Medicare.
02
Existing Medicare providers who need to update their information.
03
Organizations or entities providing services eligible for Medicare reimbursement.

Who needs a CMS Form 116?

According to the United States Federal Law, every facility which deals with doing laboratory testings on humans (excluding basic researches and clinical trials) must comply with CIA standards. To be legally allowed to perform this type of activities, a laboratory facility has to be officially acknowledged as a clinical laboratory. The results achieved by such facilities are to be used for establishing diagnoses, preventing and treating diseases, and making general health condition assessments.

CIA regulations should be fulfilled even in case a laboratory performs one of few basic test free of charge.

What is the CIA Application for Certification Form for?

The Clinical Laboratory Improvement Amendments Application for Certification has been created to collect operation data about a laboratory facility. It will be used for defining the type of certificate to issue and fees to charge.

As for the types of CIA Certificates, they can be as follows:

    Certificate of Waiver

    Certificate for Provider-Performed Microscopy Procedures (PPM)

    Certificate of Compliance

    Certificate of Accreditation

However, typically if the CMS Form 116 is filed for the first time as an initial application, the laboratory in most will be issued a Certificate of Registration. Right after an inspection is conducted, another type of certificate will be provided.

Is Form CMS-116 accompanied by other forms?

It is strongly recommended that the applying facility contacts their State Agency for additional requirements as for supporting documentation, forms or statements as they vary from one state to another. In fact, this is true not only regarding the state of laboratory operation, but also regarding the type of CIA Certificate applied for. For instance, supervising personnel of laboratory where nonwaived tests and PPM procedures are performed must comply with certain requirements as for educational and training background and experience. Therefore, in such a case, the confirmation of these requirements being met must be attached to a completed CMS-116 form.

When is CMS Form 116 due?

A process of the CMS-116 application revision is quite time-consuming, as it can take up to two months. Nevertheless, a laboratory facility can start its work as soon as their payment of a registration fee is credited. And in about two weeks, the requested Certificate will be delivered.

The CIA Certificate is valid for two years. To renew the certificate in a timely manner, it is necessary to file a new CMS-116 form with no less than nine months prior to the effective certificate's expiration date. And if the form is filed and payment made until the due date, the renewed Certificate will be received one month before the current Certificate’s expiration date.

How do I fill out the CIA Application for Certification Form?

The application should provide relevant information on the following items:

    Facility’s general information (type of application, name, address, email, name of director, etc.);

    Type of requested certificate and appropriate testing (indicated further);

    Type of laboratory;

    Hours of testing;

    Single/multiple sites;

    Type of control;

    Director affiliation with other laboratories;

    Owner/director’s signature and date

Where do I send CMS Form 116?

The completed Clinical Laboratory Improvement Amendments Application for Certification must be submitted to the local State Agency in the State where the laboratory testing will be performed. The full list of addresses and other contact information can be found in this online PDF document.

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People Also Ask about

Can I transfer my CLIA certificate to the new owners? Yes. The new owners can request a transfer by completing a CMS-116 Application Form and a CLIA Ownership Information form" found under CERTIFICATION & FEES on webpage.
What is a Waived Test? Based on the complexity of the tests, CLIA tests are categorized into three levels: waived, moderate complexity, and high complexity tests. CLIA defines waived tests as “Simple laboratory examinations and procedures that have an insignificant risk of an erroneous result.”
The CLIA application (Form CMS-116) collects information about your laboratory's operation which is necessary to determine the fees to be assessed, to establish baseline data and to fulfill the statutory requirements for CLIA. This information will also provide an overview of your facility's laboratory operation.
For a change in certificate type you must complete the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION marked for a change in certificate type. Make sure you follow instructions to complete and submit all the requested information including the List of Tests Performed in the Facility.
Waived tests are simple tests with a low risk for an incorrect result. Nonwaived tests, also called Moderately Complex tests, are those tests that require a number of criteria to be met prior to the operator running the tests.

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CMS-116 is a form used by healthcare providers to report certain information related to their services, specifically for Medicare and Medicaid purposes.
Healthcare providers and suppliers who participate in Medicare or Medicaid programs are required to file CMS-116.
To fill out CMS-116, providers should clearly follow the instructions provided on the form, ensuring that all required fields are completed accurately with relevant information.
The purpose of CMS-116 is to collect necessary information from healthcare providers to ensure compliance with Medicare and Medicaid requirements and to facilitate proper reimbursement.
Reported information on CMS-116 typically includes provider demographics, services offered, and certifications to verify compliance with federal regulations.
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