The Agency for Health Care Administration / Clinical Laboratories / Clinical Laboratory / Agency for CLIA / APPLICATION CHECKLIST Health Care Licensing Application CLINICAL LABORATORIES / Health Care Licensing Application CLINICAL LABORATORIES / Non-Waived Laboratories / Corporation Limited Liability Company Partnership / Agency for Health Care Administration Case / Profit Public Corporation / Cogent Systems / Exclusive Use Laboratory / Religious Affiliation Limited Liability Company / /
Currency
USD / / /
Facility
Laboratory Unit / /
IndustryTerm
applications / law enforcement personnel / renewal applications / ownership applications / requested information / licensed provider / /
Organization
Laboratory Unit / Licensee AUTHORITY / officers of Management Company If / officers of Licensee TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER / officers of Licensee If / officers of Management Company TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER / Agency’s Background Screening Unit / Division of Corporations / Medicare / Department of State / Florida Department of Law Enforcement / FL Department of State / Lab Unit / / /
Position
Financial Officer / director detailing changes / board member / Director of the Lab and Financial Officer / physician / OWNERSHIP INTEREST Director/CEO President Vice President Secretary Treasurer / consultant / Director The Lab and co-director / officer / director / this documentation / director describing / applicable Financial Officer / dentist / Director for the Lab and co-director / laboratory supervisor / director / Administrator / Clinical Consultant / chiropractor / laboratory director / podiatrist / /
APPLICATION CHECKLIST Health Care Licensing Application CLINICAL LABORATORIES – NON-WAIVED Including Provider-Performed Microscopy (PPM) Applicants must include the following attachments as stated in Chapter 483, Part