CLIA Form 1513 2012-2025 free printable template

Name of Entity D/B/A CIA No. EIN Telephone No. and Fax No. Street Address City, County, State Zip Code II. Answer the following questions by checking Y s” or “No”. If any of the question are

How to fill out form 1513 disclosure form

How to fill out CLIA Form 1513

1. Obtain a copy of CLIA Form 1513 from the CMS website or your state health department.
2. Fill in the applicant's name and address in the specified fields.
3. Indicate the type of laboratory and select the appropriate category.
4. Provide the name and contact information of the laboratory director.
5. Enter the physical address of the laboratory performing the tests.
6. Indicate the type of tests that will be performed in the laboratory.
7. Complete the information regarding the laboratory’s ownership and operation.
8. Review the form for accuracy and completeness.
9. Submit the completed form according to the instructions provided.

Who needs CLIA Form 1513?

1. Any laboratory that conducts clinical testing must complete CLIA Form 1513 to comply with the Clinical Laboratory Improvement Amendments regulations.

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What is CLIA Form 1513?

CLIA Form 1513 is a form used for laboratories to apply for a Clinical Laboratory Improvement Amendments (CLIA) certification, which ensures that laboratory testing meets federal standards.

Who is required to file CLIA Form 1513?

Any laboratory that conducts testing on human specimens for health assessment, diagnosis, or treatment must file CLIA Form 1513 to obtain the proper certification.

How to fill out CLIA Form 1513?

To fill out CLIA Form 1513, individuals must provide information such as the laboratory's name, address, type of services provided, and ownership details, along with any applicable fees.

What is the purpose of CLIA Form 1513?

The purpose of CLIA Form 1513 is to assess and confirm laboratory compliance with federal regulations regarding the quality and accuracy of laboratory testing.

What information must be reported on CLIA Form 1513?

Information required on CLIA Form 1513 includes laboratory identification, types of tests performed, ownership structure, personnel qualifications, and facility accreditation details.