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CMS-116 2014 free printable template

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The number will be assigned when the application is processed. For all other applicants enter the 10 digit CLIA identification number already assigned and listed on your CLIA certificate. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0581 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CLIA APPLICATION FOR CERTIFICATION I. The CLIA application Form CMS-116 collects information about your laboratory s operation which is necessary to...
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How to fill out clia application 2014 form

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How to fill out CMS-116

01
Obtain the CMS-116 form from the CMS website or your local Medicare office.
02
Fill out the provider's name and address in the designated fields.
03
Provide the appropriate National Provider Identifier (NPI) number.
04
Indicate the type of services offered by checking the relevant boxes.
05
Complete the sections related to patient information as required.
06
Ensure that all required signatures are provided at the end of the form.
07
Double-check the information for accuracy and completeness.
08
Submit the completed form as per the instructions provided with it.

Who needs CMS-116?

01
Healthcare providers seeking to enroll or update their information in Medicare.
02
Facilities looking to bill for Medicare services.
03
Organizations that need to report changes to their provider status.

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

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.”
On each claim, the CLIA number of the laboratory that is actually performing the testing must be reported in item 23 on the CMS-1500 form.
Clinical Laboratory Improvement Amendments (CLIA) Section This process involves compliance with the federal Clinical Laboratory Improvement Amendments (CLIA) of 1988, which requires that all laboratories testing human specimens be certified by the federal government.
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.
Clinical Laboratory Improvement Amendments (CLIA)
The Clinical Laboratory Improvement Amendments (CLIA) Program regulates labs testing human specimens and ensures they provide accurate, reliable, and timely patient test results no matter where the test is done. CMS oversees all lab testing (except some research) done on humans in the U.S. through CLIA.

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CMS-116 is a form used by the Centers for Medicare & Medicaid Services (CMS) to collect data from certain healthcare providers regarding their compliance with federal regulations and operational standards.
Healthcare providers that participate in CMS programs, including Medicare and Medicaid, are required to file CMS-116. This includes facilities such as hospitals, nursing homes, and other institutions.
To fill out CMS-116, complete the required fields with accurate information regarding your facility, operations, and compliance practices. It is essential to follow the instructions provided by CMS to ensure accuracy and completeness.
The purpose of CMS-116 is to gather information to assess the quality of care and compliance with federal regulations among healthcare facilities. This data is used for regulatory oversight and quality improvement initiatives.
CMS-116 requires reporting information such as facility identification, types of services provided, staffing details, compliance records, and any other data relevant to operational practices and regulatory adherence.
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