Medical Laboratories Forms

School Districts Laboratory Application

In an effort to address the COVID-19 pandemic, the Federal Government through the Centers for Medicare and Medicaid Services (CMS), is moving forward with securing and distributing COVID-19 testing supplies to the K through 12 school system. To take advantage of this testing capability, each participating school district will be required to have a state of Nevada laboratory license and a Federal CLIA (Clinical Laboratory Improvement Amendments) certificate. For more information, click on the PDF linked below.

• Application Process for School Districts to Obtain an Exempt Laboratory License to Perform COVID-19 Waived Testing

APPLY ONLINE FOR ALL MEDICAL LABORATORY & LABORATORY PERSONNEL APPLICATIONS by going to the Division's online licensing system at https://nvdpbh.aithent.com/login.aspx

Medical Laboratory and Laboratory Personnel applications below should only be completed and mailed in if you are unable to submit an electronic application by clicking on the link above.

CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) FORMS

• CMS-116 
• CLIA Disclosure of Ownership & Control Interest Statement (Form 1513) 
• Instructions for Completing Disclosure of Ownership and Control Interest Statement (Form 1513)

ONLINE SUPPLEMENTAL FORMS (To be used only as directed when applying online via the online licensing system)

• Laboratory Director Verification Form 
• Online Exempt Laboratory Checklist Items  
• Online Exempt-Outpatient Laboratory Checklist Items 
• Online Registered Laboratory Checklist Items 
• Online Licensed Laboratory Checklist Items 
• Online Public Health Licensed Laboratory Checklist Items 
• Waived HIV Test Only Laboratory Checklist Items 
• Office Laboratory Assistant Application Employment Verification Form