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Laboratory Field Services

Forms

Download forms using the links below. Clicking a link will open another tab in your browser. You can also download by right-clicking the link and choosing "Save."

State Forms

​ LAB 116 (pdf) ​- Laboratory Personnel Report
​ LAB 144 (pdf) - ​Initial Application (License)
​  LAB 144A (pdf) ​- Laboratory Testing Declaration
 ​ LAB 144B (pdf) ​- Application for Additional Testing Site
​  LAB 144R (pdf) ​- Application to Renew (License)
​  LAB 155 (pdf) ​- Initial Application (Registration)
​  LAB 155R (pdf) ​- Application to Renew (Registration)
​  LAB 167 (pdf) ​- Annual Test Volume
​  LAB 182 (pdf) ​- Owner's Attestation
​  LAB 183 (pdf) ​- Laboratory Director's Attestation
​  LAB 193 (pdf) ​- Notification of Laboratory Change
​  LAB 1513 (pdf) ​- Disclosure of Ownership and Control Interest Statement

Federal Forms

 ​CMS 116 (pdf) ​- CLIA Application for Certification
 ​CMS 209 (pdf) ​- CLIA Laboratory Personnel Report

Related Links

 ​Payment Request Sheet (pdf) ​- Mail-in payment request for an online application

Send to LFS

​mailit

​Mail to:
California Department of Public Health
Laboratory Field Services
850 Marina Bay Parkway
Bldg. P, 1st Floor
Richmond, CA  94804-6403
​emailit

​Email to:
LFScc@cdph.ca.gov

  • Subject line: Include any reference such as State ID, CLIA ID, application ID, and facility name.
  • Body of email: Include information such as type of application (initial, renewal, changes, etc.)
​uploadit

​Upload Online:                     
Upload the completed and signed forms in your application.

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