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PRINTED: 01/12/2024 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

How to fill out form cms-116 clia application

How to fill out form cms-116 clia application

1. Gather all necessary information and documents required for the application such as the laboratory name, CLIA number, contact information, testing personnel information, director information, and testing menu.
2. Access the CMS-116 CLIA application form on the CMS website or obtain a physical copy from the CLIA State Agency.
3. Carefully read the instructions provided on the form and fill out all the required fields accurately. Ensure to provide all necessary supporting documentation as well.
4. Submit the completed application form along with any required fee to the appropriate CLIA State Agency for processing.
5. Wait for approval from the CLIA State Agency before conducting any testing under the CLIA program.

Who needs form cms-116 clia application?

1. Any laboratory that performs clinical testing on human specimens for the purpose of providing information for the diagnosis, prevention, or treatment of disease or the assessment of health may need to fill out form CMS-116 CLIA application.

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What is form cms-116 clia application?

The CMS-116 form is an application used to apply for a CLIA (Clinical Laboratory Improvement Amendments) certificate, which allows laboratories to conduct testing on human specimens.

Who is required to file form cms-116 clia application?

Any laboratory that performs tests on human specimens and intends to receive payment from Medicare or Medicaid is required to file the CMS-116 application.

How to fill out form cms-116 clia application?

To fill out the CMS-116 application, gather necessary information about the laboratory, including its ownership, address, type of tests performed, and personnel qualifications. Complete the form clearly and submit it to the appropriate state agency or CMS regional office.

What is the purpose of form cms-116 clia application?

The purpose of the CMS-116 form is to provide the Centers for Medicare & Medicaid Services (CMS) with essential information regarding a laboratory's operations to ensure compliance with federal regulations.

What information must be reported on form cms-116 clia application?

The CMS-116 application requires information such as the laboratory's name, address, ownership details, types of tests performed, and credentials of laboratory personnel.