Transcription of DEPARTMENT OF HEALTH AND HUMAN SERVICES …
{{id}} {{{paragraph}}}
Example: biology
DEPARTMENT OF HEALTH AND HUMAN SERVICES …
DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0581. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA). APPLICATION FOR CERTIFICATION. I. GENERAL INFORMATION. CLIA IDENTIFICATION NUMBER. Initial Application Survey Change in Certificate Type D. Closure/Other Changes (Specify). (If an initial application leave blank, a number will be assigned). Effective Date FACILITY NAME FEDERAL TAX IDENTIFICATION NUMBER. EMAIL ADDRESS TELEPHONE NO. (Include area code) FAX NO. (Include area code). FACILITY ADDRESS Physical Location of Laboratory (Building, Floor, Suite MAILING/BILLING ADDRESS (If different from facility address) send Fee if applicable.) Fee Coupon/Certificate will be mailed to this Address unless Coupon or certificate mailing or corporate address is specified NUMBER, STREET (No Boxes) NUMBER, STREET. CITY STATE ZIP CODE CITY STATE ZIP CODE. SEND CERTIFICATE TO THIS ADDRESS SEND FEE COUPON TO THIS ADDRESS CORPORATE ADDRESS (If different from facility) send Fee Coupon or certificate Physical Physical Mailing Mailing NUMBER, STREET.
1 . email address . corporate address. name of director . department of health and human services . form approved . centers for medicare …
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
REQUEST DOCUMENT NORTH, Request document north dakota department of health division, North dakota department of health, NORTH DAKOTA PHYSICAL EDUCATION, NORTH DAKOTA PHYSICAL EDUCATION CONTENT STANDARDS Grades, Of Health, North Dakota Department, State Public Health, Dakota, State Public Health Veterinarian, Dakota Department of Health, To The Employer, Job Service North Dakota, NORTH DAKOTA, IN DEMAND OCCUPATIONS, Job Service North, North Dakota Provider Exclusion List Updated