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Laboratory Registration Or Licensure Application Form. This is a Nevada form and can be use in Health Division Statewide.
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Tags: Laboratory Registration Or Licensure Application, Nevada Statewide, Health Division
LABORATORY REGISTRATION
OR LICENSURE APPLICATION
Page 1 of 2
NEVADA STATE HEALTH DIVISION
Bureau of Health Care Quality and Compliance
727 Fairview Drive, Suite E
Carson City, Nevada 89706
Phone: (775) 684-1030 Fax: (775) 684-1075
http://www.health.nv.gov/HCQC_Medical.htm
This application must be accompanied by a check for the appropriate amount made payable to the Nevada State Health Division.
Under Nevada Administrative Code (NAC) 652.488 the fee is non-refundable. Insufficient funds charge: $25.00 per NAC 353C.400.
Regulations may be viewed at http://leg.state.nv.us.
Current State Lab Number:
This application is for:
Licensed Lab (Services to General Public)
Fees are based on test volume:
Less than 25,000
= $1,100.00
25,000 and less than 100,000 = $3,000.00
100,000 or more = $4,000.00
Registered Lab (Private Practice)
Fee $1,500.00
Reactivation (Same fee as initial)
Ownership (Same fee as initial)
Changes to an existing lab (check all that apply):
Existing
Add Tests
Director
Location
Name
New
The fee for making any changes to the director, location, name or test addition of the lab is $300.00, plus $50.00 for each additional
specialty.
Laboratory/Business Name
Doing Business As (DBA)
Phone Number (starting with the area code)
Fax Number (starting with the area code)
Street Address
Mailing Address (if different from street address)
City
City
County
County
State
State
Zip Code
Zip Code
Director
General Supervisor
Hours of Operation
Contact Person and Phone Number
CLIA Type (or attach application HCFA 116)
CLIA Number
Ownership Information:
List names and addresses of all individuals or organizations having direct or indirect ownership or control of 10% or more in the lab
NRS 652.090. Please attach a complete listing if additional space is needed.
Name
Address
11/30/2010
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LABORATORY REGISTRATION OR LICENSURE
APPLICATION
Page 2 of 2
TESTS PERFORMED IN THE LABORATORY
Histocompatibility
Transplant
Nontransplant
Chemistry
Routine
Urinalysis
Endocrinology
Toxicology
Other
Hematology
Microbiology
Bacteriology
Mycobacteriology
Mycology
Parasitology
Virology
Other
Clinical Cytogenetics
Radiobioassay
Immunohematology
ABO Group & Rh Type
Antibody Detection (transfusion)
Antibody Detection (nontransfusion)
Antibody Identification
Compatibility Testing
Other
Diagnostic Immunology
Syphilis Serology
General Immunology
Laboratory Type:
Private
Government
Pathology
Histopathology
Oral Pathology
Cytology
Non-profit
Corporation (List Corporate Directors’ name(s) and addresses)
List all modules of Proficiency Testing program enrollment:
List name, address and phone number of individual(s) responsible for records in the event the laboratory closes:
Name
Address
Phone Number
Required Documents:
1
Copy of all current physicians’ licenses (wallet size is acceptable) – Per NAC 652.470
2
Attach a list of personnel performing test and/or collecting specimens – Per NRS 652.210
DIRECTOR’S SIGNATURE MUST BE NOTARIZED
I have read understood and agree to comply with the rules and regulations pertaining to the specific type of facility for which licensure
applications are herein made.
Lab Physician/Director’s Signature
Please PRINT and SIGN Name
Must be an ORIGINAL: photocopies or signature stamps are not
acceptable.
Name and Signature of Notary:
Date:
State of:
County of:
Subscribed and sworn before me this:
Day of:
11/30/2010
American LegalNet, Inc.
www.FormsWorkFlow.com