Printable Maryland Laboratory Licensing Template

The Maryland Laboratory Licensing form is a crucial document used for making changes and updates to laboratory information in the state. It ensures that all modifications are properly documented and that the laboratory remains compliant with state regulations. If you need to update your laboratory's details, click the button below to fill out the form.

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The Maryland Laboratory Licensing form serves as a crucial document for laboratories seeking to update their licensing information with the Office of Health Care Quality. This form is specifically designed for changes and updates, allowing laboratories to communicate alterations in various operational aspects. Key sections include the current name of the lab, state lab ID, and federal CLIA number, which must be accurately filled out to ensure compliance. The form requires the laboratory director's signature to validate any changes, emphasizing the importance of oversight in laboratory management. Additionally, laboratories must provide details regarding changes in ownership, director information, and physical or mailing addresses. The form also includes a section for laboratories to list tests they are adding or deleting, specifying the instruments or kits used and the effective date of each change. Furthermore, laboratories can indicate changes to their state license status and CLIA certification status, necessitating the submission of additional documentation as needed. This structured approach not only streamlines the licensing process but also helps maintain the integrity and quality of laboratory services in Maryland.

Maryland Laboratory Licensing Preview

Maryland Department of Health and Mental Hygiene 

Office Use Only 

Office of Health Care Quality – Laboratory Licensing Programs  Date Received: 

Spring Grove Center – Bland Bryant Building  Check #: 

55 Wade Avenue, Catonsville, MD 21228  Amount: 

Phone: 410.402.8025 Fax: 410.402.8213  Date Completed: 

Laboratory Licensing Change Form

This form is for changes and updates only. Please only provide us with the changes in the fields below along with the effective date of the change.

For a change of Director, a copy of the Director’s medical license, medical diploma and board certification must be submitted. Please send diploma and CV for a PhD Director. This form must be signed by the Director for these changes to be valid.

***THIS FORM MUST BE SIGNED BY THE DIRECTOR FOR ALL CHANGES TO BE VALID.***

Please return this form by fax:

410-402-8213

Or by mail:

Attention: Lab Licensing, OHCQ – Bland Bryant Building,

55 Wade Avenue, 1st Floor, Catonsville, MD 21228

Current Name of Lab: ___________________________

State Lab ID # __________ Federal CLIA #: ___________ Is this CLIA a multisite? Y N

Laboratory Name:	________________________________	Date of Change: ___________
Owner:	________________________________	Date of Change: ___________
Tax ID #:	________________________________	Date of Change: ___________
Director:	________________________________	Date of Change: ___________
Physical Address:	________________________________	Date of Change: ___________
	________________________________
Mailing/Billing Address: _____________________________		Date of Change: ___________
	_____________________________
Telephone #:	________________________________	Date of Change: ___________
Fax #:	________________________________	Date of Change: _________

Please list the tests you are adding or deleting from your current test menu. Please use the chart below and indicate for each test the instrument/kit used as well as the effective date of change.


		Changes/Additions/Deletions to Tests
Test Name		Kit/Instrument Used		Add Delete	Date of Change
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
______________		___________________			_____________
Change State License Status to:
Letter of Exception		General Permit		Date of Change: ____________
Change my CLIA Certification Status to: (must submit with a CMS-116)
Waiver	Compliance		Provider Performed Microscopic Procedures (PPMP)

Accreditation with which program? ____________________________________________

Date of Change: _________________________

____________________________________________________________________________

Our office has closed and/or discontinued all clinical testing. Date of Change: __________

Print Laboratory Director’s Name: ________________________________________________

Laboratory Director’s Signature: _______________________________ Date: _____________

Click for Maryland Laboratory Licensing File

Form Attributes

Fact Name	Details
Governing Authority	This form is governed by the Maryland Department of Health and Mental Hygiene.
Purpose	The Laboratory Licensing Change Form is specifically for reporting changes and updates to laboratory information.
Director's Signature Requirement	All changes submitted must be signed by the laboratory director for them to be considered valid.
Submission Methods	The form can be submitted via fax or by mail to the Office of Health Care Quality.
Contact Information	For inquiries, the laboratory can contact the office at 410-402-8025.
CLIA Certification	Changes to CLIA certification status require submission of a CMS-116 form.
Test Menu Changes	Laboratories must list any tests being added or deleted, including the instrument or kit used.
Address for Submission	Forms should be sent to: Lab Licensing, OHCQ – Bland Bryant Building, 55 Wade Avenue, 1st Floor, Catonsville, MD 21228.

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