Initial Clinical Laboratory Application
Note: Please complete the Initial Application if you wish to upgrade your Waived license to either Non-Waived or to add Provider-performed Microscopy.
The initial application is also needed if you are downgrading your Non-Wavied lab to Wavied.
Required Clinical Laboratory Application Fees:
Laboratory application fees are dependent upon the type of laboartory and the volume of tests preformed
Background Screening:
Level 2 Background Screening must be completed for the laboratory director and the chief financial officer prior to approving the initial application and then repeated every five years. Please go to the background screening section of this web site for additional documentation that must be submitted with your application. Fingerprint cards are available by contacting the Laboratory Unit at 850-487-3109. Other fingerprint cards may not be acceptable.
Annual Affidavit of Background Screening Compliance
Each non - waived laboratory is required by section 435.04(05), Florida Statutes(2006) to submit an affidavit of compliance with this section. A recommended form is available at this the link below.
| NOTE: If after reviewing the application forms and statutory and rule requirements on our website you have additional questions, please call (850) 487-3109. Staff will be happy to answer questions that clarify the requirements as they apply to your specific situation, but cannot walk you through the application. Filling out the application is part of your responsibility as an applicant. The Agency's role in this process is to evaluate your application and, if there are elements missing from your application once submitted, provide you with an omissions response that gives you another opportunity to complete the application successfully. If you need extensive assistance in filling out your application, we would advise you to retain an attorney or a government relations consultant to assist you. |
Separate forms are available for those responding to staff omission requestions. Note: All applicants must complete the information in items 1 through 5. Laboratories performing waived testing and provider-performed microscopy procedures (PPMP) must also complete item 6. Directors and Financial Officers of nonwaved laboratories must complete item 7.
- Initial State Laboratory Licensure Application, checklist, fee schedule and test menu form (AHCA FORM 3000-4)
- Health Care Licensing Application
- Health Care Licensing Application Addendum
- Declaration of Proposed Test Menu
- Volunteer Board Member Affidavit
- Microscopy Evaluation Survey (complete if applying for "Provider-performed Microscopy" testing): (72kb.pdf)
- Affidavit of Compliance with Background Screening Requirements
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