Laboratory Registration Or Licensure Application
Laboratory Registration Or Licensure Application Form. This is a Nevada form and can be use in Health Division Statewide.
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 American LegalNet, Inc. www.FormsWorkFlow.com 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