Clia Certificate Type Change Form - Illinois

This Illinois-specific printable "Clia Certificate Type Change Form" is a part of the legal paperwork issued by the Illinois Department of Public Health.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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State of Illinois
CLIA Laboratory Certification Program
Phone: 217-782-6747
FAX: (217) 782-0382
CLIA CERTIFICATE TYPE CHANGE
CLIA Certificate Number (number typically begins with 14D) ___________________
NOTE: For Certificate Changes to PPM, Compliance or Accredited, Submit a
New CMS-116 Application
Select Current Certificate Type: CLIA PPM
Compliance
Accredited
Change to: AABB
AOA
ASHI
A2LA
Change To: CLIA Waived
CAP
COLA
The Joint Comm
Facility Name (Print) ______________________________________________________________________
Address _______________________________________________ State _________ Zip Code __________
E-mail ______________________________________ Phone # _______________ Fax # _______________
Certificate changes to CLIA waived requires list of test names and volumes: (Certificate allows only
waived tests to be performed).
CLIA waived ESTIMATED yearly test volume _____________________
1. List the name of all CLIA waived tests that you expect to perform (Example: Rapid Strep, Acme
Home Glucose Meter, etc.).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
COMPLETE THE SECTION BELOW ONLY IF THE CERTIFICATE WILL HAVE A NEW LAB
DIRECTOR OR CHECK the NO box
AND SIGN (fax/mail scan/e-mail form)
New Director’s Name (Print) ________________________________________________________________
New Director’s Signature - _________________________________________ Date ____________________
Person Requesting Change (Print) ____________________________________________________________
Signature _____________________________________________________ Date ______________________
Forms can be faxed to 217-782-0382, scanned/e-mailed or
Mailed to IDPH CLIA Laboratory Certification Program, 525 W. Jefferson St., 4th Floor,
Springfield, IL 62761
State of Illinois
CLIA Laboratory Certification Program
Phone: 217-782-6747
FAX: (217) 782-0382
CLIA CERTIFICATE TYPE CHANGE
CLIA Certificate Number (number typically begins with 14D) ___________________
NOTE: For Certificate Changes to PPM, Compliance or Accredited, Submit a
New CMS-116 Application
Select Current Certificate Type: CLIA PPM
Compliance
Accredited
Change to: AABB
AOA
ASHI
A2LA
Change To: CLIA Waived
CAP
COLA
The Joint Comm
Facility Name (Print) ______________________________________________________________________
Address _______________________________________________ State _________ Zip Code __________
E-mail ______________________________________ Phone # _______________ Fax # _______________
Certificate changes to CLIA waived requires list of test names and volumes: (Certificate allows only
waived tests to be performed).
CLIA waived ESTIMATED yearly test volume _____________________
1. List the name of all CLIA waived tests that you expect to perform (Example: Rapid Strep, Acme
Home Glucose Meter, etc.).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
COMPLETE THE SECTION BELOW ONLY IF THE CERTIFICATE WILL HAVE A NEW LAB
DIRECTOR OR CHECK the NO box
AND SIGN (fax/mail scan/e-mail form)
New Director’s Name (Print) ________________________________________________________________
New Director’s Signature - _________________________________________ Date ____________________
Person Requesting Change (Print) ____________________________________________________________
Signature _____________________________________________________ Date ______________________
Forms can be faxed to 217-782-0382, scanned/e-mailed or
Mailed to IDPH CLIA Laboratory Certification Program, 525 W. Jefferson St., 4th Floor,
Springfield, IL 62761
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