State of Idaho Laboratory Registration Form
Idaho Bureau of Laboratories
Laboratory Improvement Section
208-334-2235 ext. 246
For Office Use Only

CLIA #:

State Registration #: 

Instructions
1.  All items must be completed. If you have any questions, please call the Laboratory Improvement Section at 208-334-2235 ext. 246.
2.  The Laboratory Director must be a person qualified under the CLIA regulations. Most physicians will qualify as the director of their office labs.
3.  The contact person should be someone familiar with the laboratory's operations and the person who will be contacted with any questions about this form.
4.  The technical consultant position is only required for full certificate laboratories. This person must qualify under the CLIA regulations for technical consultant.
5.  The clinical consultant must be an MD or DO who qualifies under the CLIA regulations to provide consultation to a full certificate laboratory.
6.  A copy of your completed form will be emailed to the email address provided upon form completion.  Retain this for your records.

NOTE:  Labs beginning operation or changing existing information must also complete the Federal CLIA Lab Registration Form.
By submitting this form, you are certifying that the information contained herein is true and correct to the best of your knowledge.
Form revised 11/2014
Waivered Procedures
Provider-performed Microscopy
Non-waived Testing
Application type:

CLIA or State Lab Registration Number:

Please complete the following information (required):



Level of CLIA Certificate (level must match test procedures selected below), select all that apply:

Please complete the following information for Compliance and Accredited labs:

Urinalysis

Other


Hematology

Microbiology



Chemistry



Immunology



Chemistry



Immunology

Immunohematology

Hematology




Coagulation


Microbiology