Form LAB 182 Owner's Attestation - California

Form LAB182 is a California Department of Public Health form also known as the "Owner's Attestation". The latest edition of the form was released in December 1, 2017 and is available for digital filing.

Download an up-to-date Form LAB182 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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State of California—Health and Human Services Agency
California Department of Public Health
OWNER’S ATTESTATION
I attest that effective
, I am the laboratory owner, or a co-owner of:
(date)
clinical laboratory, located at
(name of laboratory)
(street address)
CLIA ID number
:
State ID number (if known):
As the owner or co-owner, I understand I am legally responsible for the operation of the laboratory under
both CLIA and S tate law. I understand that as an owner of this laboratory, I, along with the director, must
ensure the accuracy and reliability of all testing per formed and that the laboratory meets a ll applicable
CLI A and state requirements .
I understand that I will be held jointly and severally responsible with the laboratory director(s) for the
maintenance and conduct of the laboratory and all employees therein or for any violations of law by this
clinical laboratory (Business and Professions Code (BPC) section 1265(b)). If deficie nt or unlawful
practice s are fo und that oc curred wh ile I was serving as laboratory owner or co-owner, which th e
laborator y fails or is unabl e to correct, and which results in the revocatio n of th e laboratory’s CLIA
certificate or state license or registration, I understan d that pursuant to Title 42 of th e United States Code
(USC ), section 263(a)(i) (3), 42 CFR 493.1840(a)(8), and BPC secti on 1324, I would be prohibite d from
owning, op erating, or directi ng anot her clinic a l laboratory for a period of at le ast two years fr om the dat e of
revocati on. Such acti on may also be grounds for referra l to the Medical Board of California or other
licensing board for appropriate action.
I understand that any reasons listed in BPC section 1320, including any fals e statement or representation
of fact in obtaining or r etaining CLIA certific ation or state licens ure or registration may be grounds for
revocation of the laboratory’s CLIA certificate under 42 CFR 493 .1840(a)(1), and state license or
registration under BPC section 1320 and may subject me to criminal or civil sanctions.
I understand that I will be responsible, along with the laboratory director(s), to n otify the Department of
Public Health in writing of any changes in the laboratory owners hip, dir ectorship, name or loc ation within
thirty days of the change, and that failure to provide such not ification will result in automatic revocation of
the state license or registration (BPC section 1265(g)), and sanctions against the CLIA certificate ( 42
CFR 493.39(b), 493.45(b)(2), 493.51(a), 493.53(a), 493.57(a)(2), and 493.63(a)).
I understand that I will c ontinue to be held r es ponsible as a laboratory owner of this laboratory until the
day that the California Department of Public Health receives a signed statement from me notifying the
Department of my resignation or termination.
I affirm under penalty of perjury, that all information I have given in this document is true. This statement
must be signed by the owner or a person legally authorized by the owner.
Date
Owner or Authorize Representative’ s signature
Prin t or ty pe nam e and title
Owner 's contac t telephone number
Owner ’s address
LAB 182 (12/17)
State of California—Health and Human Services Agency
California Department of Public Health
OWNER’S ATTESTATION
I attest that effective
, I am the laboratory owner, or a co-owner of:
(date)
clinical laboratory, located at
(name of laboratory)
(street address)
CLIA ID number
:
State ID number (if known):
As the owner or co-owner, I understand I am legally responsible for the operation of the laboratory under
both CLIA and S tate law. I understand that as an owner of this laboratory, I, along with the director, must
ensure the accuracy and reliability of all testing per formed and that the laboratory meets a ll applicable
CLI A and state requirements .
I understand that I will be held jointly and severally responsible with the laboratory director(s) for the
maintenance and conduct of the laboratory and all employees therein or for any violations of law by this
clinical laboratory (Business and Professions Code (BPC) section 1265(b)). If deficie nt or unlawful
practice s are fo und that oc curred wh ile I was serving as laboratory owner or co-owner, which th e
laborator y fails or is unabl e to correct, and which results in the revocatio n of th e laboratory’s CLIA
certificate or state license or registration, I understan d that pursuant to Title 42 of th e United States Code
(USC ), section 263(a)(i) (3), 42 CFR 493.1840(a)(8), and BPC secti on 1324, I would be prohibite d from
owning, op erating, or directi ng anot her clinic a l laboratory for a period of at le ast two years fr om the dat e of
revocati on. Such acti on may also be grounds for referra l to the Medical Board of California or other
licensing board for appropriate action.
I understand that any reasons listed in BPC section 1320, including any fals e statement or representation
of fact in obtaining or r etaining CLIA certific ation or state licens ure or registration may be grounds for
revocation of the laboratory’s CLIA certificate under 42 CFR 493 .1840(a)(1), and state license or
registration under BPC section 1320 and may subject me to criminal or civil sanctions.
I understand that I will be responsible, along with the laboratory director(s), to n otify the Department of
Public Health in writing of any changes in the laboratory owners hip, dir ectorship, name or loc ation within
thirty days of the change, and that failure to provide such not ification will result in automatic revocation of
the state license or registration (BPC section 1265(g)), and sanctions against the CLIA certificate ( 42
CFR 493.39(b), 493.45(b)(2), 493.51(a), 493.53(a), 493.57(a)(2), and 493.63(a)).
I understand that I will c ontinue to be held r es ponsible as a laboratory owner of this laboratory until the
day that the California Department of Public Health receives a signed statement from me notifying the
Department of my resignation or termination.
I affirm under penalty of perjury, that all information I have given in this document is true. This statement
must be signed by the owner or a person legally authorized by the owner.
Date
Owner or Authorize Representative’ s signature
Prin t or ty pe nam e and title
Owner 's contac t telephone number
Owner ’s address
LAB 182 (12/17)

Download Form LAB 182 Owner's Attestation - California

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