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Changes to Current Certificates

Complete Form CMS-116 when any of the following changes take place:

  • Recertification Survey
  • All Certificates Changes other than downgrading to a Certificate of Waiver
  • Reinstatement of CLIA certificate
  • Director Change – Certificate of Provider Performed Microscopy or Compliance

Written notification or a complete CMS-116 must be provided when the following changes occur:

  • Ownership -  In addition to the CMS-116, you must submit an Internal Revenue Service (IRS) Form SS-4
  • Tax ID (EIN) - In addition to the CMS-116, you must submit an Internal Revenue Service (IRS) Form SS-4
  • Status Change downgrading to Certificate of Waiver
  • Name of Laboratory
  • Location (Physical Location)
  • Mailing Address
  • Specialty Change
  • Total Volume Change
  • Telephone and Fax Numbers
  • Reinstatement
  • Change in Accreditation Organization
  • Voluntary Closure/Termination
  • Personnel – Technical Supervisor
  • Director Change – Certificate of Waiver

Written (hard copy, fax or hard copy letter) notification must include:

  • Laboratory name
  • CLIA number
  • Name of Laboratory Director
  • Change(s) being made
  • Signature of the Laboratory Director

Send written notification or complete CMS-116 to the address at the right.