Form LAB167OS "Annual Test Volume of California Specimens - out-Of-State Laboratory" - California

What Is Form LAB167OS?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2011;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LAB167OS by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form LAB167OS "Annual Test Volume of California Specimens - out-Of-State Laboratory" - California

1494 times
Rate (4.4 / 5) 75 votes
State of California — Health and Human Services Agency
California Department of Public Health
Laboratory Field Services
ANNUAL TES T VO LUME OF CALIFORNIA SPECIMENS
Out-of-State Laboratory
Indicate the annual volume of tests performed on specimens received from California by specialties or subspecialty.
Name of Laboratory
State ID Number
CLIA
Address (number, street)
City
State
ZIP
SPECIALTY/SUBSPECIALTY
ANNUAL TEST VOLUME
SPECIALTY/SUBSPECIALTY
ANNUAL TEST VOLUME
110 Bacteriology
010 Histocompatibility
115 Mycobacteriology
400 Hematology
120 Mycology
510 ABO and Rh Type
520 Antibody Detection
130 Parasitology
Transfusion
530 Antibody Detection
140 Virology
Non-transfusion
210 Syphilis Serology
540 Antibody Identification
220 General Immunology
550 Compatibility Testing
310 Routine Chemistry
610 Histopathology
320 Urinalysis
620 Oral Pathology
330 Endocrinology
630 Cytology
340 Toxicology
900 Clinical Cytogenetics
Sub-Total: _____________________________
List all other tests performed and annual test volume (Use additional sheets if necessary)
Sub-Total: _____________________________
Total Volume: __________________________
Authorized Signature: __________________________ Printed Name: _________________________ Date: _______
LAB 167OS (8/11)
State of California — Health and Human Services Agency
California Department of Public Health
Laboratory Field Services
ANNUAL TES T VO LUME OF CALIFORNIA SPECIMENS
Out-of-State Laboratory
Indicate the annual volume of tests performed on specimens received from California by specialties or subspecialty.
Name of Laboratory
State ID Number
CLIA
Address (number, street)
City
State
ZIP
SPECIALTY/SUBSPECIALTY
ANNUAL TEST VOLUME
SPECIALTY/SUBSPECIALTY
ANNUAL TEST VOLUME
110 Bacteriology
010 Histocompatibility
115 Mycobacteriology
400 Hematology
120 Mycology
510 ABO and Rh Type
520 Antibody Detection
130 Parasitology
Transfusion
530 Antibody Detection
140 Virology
Non-transfusion
210 Syphilis Serology
540 Antibody Identification
220 General Immunology
550 Compatibility Testing
310 Routine Chemistry
610 Histopathology
320 Urinalysis
620 Oral Pathology
330 Endocrinology
630 Cytology
340 Toxicology
900 Clinical Cytogenetics
Sub-Total: _____________________________
List all other tests performed and annual test volume (Use additional sheets if necessary)
Sub-Total: _____________________________
Total Volume: __________________________
Authorized Signature: __________________________ Printed Name: _________________________ Date: _______
LAB 167OS (8/11)