State Public Health Order Info
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Last updated on November 24, 2020
Dentists must adhere to the following requirements related to renewals, record retention and other regulatory compliance requirements.
✔︎ CMS 116 (PDF) — CLIA application for new or for changes in your site such as change in laboratory director, ownership, change in certificate type, address, etc. This form is not necessary if there are no changes in your site since the last renewal.
✔︎ LAB 155R (PDF) — Renewal Application for Clinical Laboratory Registration
✔︎ LAB 183 (PDF) — Director Attestation (each director or co-director must file a separate attestation)
✔︎ Renewal fee – This is usually $113, refer to the LFS fee schedule for any changes. Write your state LAB ID (e.g., XXX 123456) on your check or money order and make it payable to:
California Department of Public HealthLaboratory Field Services850 Marina Bay Pkwy, Bldg. P-1st FloorRichmond, CA 94804-6403
Please note: Lab renewal forms may have a different address listed to submit renewal applications and fees; however the most up-to-date address is the Richmond address listed above.
CMS will mail a renewal fee coupon and instructions approximately six months before expiration of the CLIA Certificate of Waiver. The renewal fee is typically $180 every two years. Click here to view the CLIA fee schedule.
Clinical laboratories, including those that have ceased operations, must retain medical and laboratory records for three years from the date of testing.
If any of the following changes occur to your practice, a filing must be submitted to LFS within 30 calendar days:
None of these filings require a filing fee, but application forms must include original signatures and be mailed to: