ATTACHMENT

 

LIST OF TESTS PERFORMED IN THE FACILITY

 

Facility Name: 

Date: 

Facility Address: 

City/State/Zip: 

Name of Person Completing Form: 

Contact Phone Number: 

Contact Email Address: 

 

*Please list the specific manufacturer’s name and model of the instrument or manufacturer’s name of the test kit used for patient testing.  For example, do not list “Hematology Machine” or “Strep Kit.”  This will ensure that you will receive the correct certificate based on the tests performed in your laboratory.

**A list of waived and/or PPMP tests and corresponding CPT codes to assist with the completion of this form can be found at the following link:  http://www.cms.gov/CLIA/10_Categorization_of_Tests.asp#TopOfPage

 

Name of Laboratory Test

*Name of Instrument or Kit Used for Testing

CPT Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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