Fillable Form Approved: CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION (Medicare & Medicaid)

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Form Approved: CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION (Medicare & Medicaid)

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1
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0581
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA)
APPLICATION FOR CERTIFICATION
I. GENERAL INFORMATION
Initial Application Survey
Change in Certificate Type
Other Changes (Specify)
Effective Date
CLIA IDENTIFICATION NUMBER
D
(If an initial application leave blank, a number will be assigned)
FACILITY NAME FEDERAL TAX IDENTIFICATION NUMBER
EMAIL ADDRESS TELEPHONE NO.
(Include area code) FAX NO. (Include area code)
FACILITY ADDRESS — Physical Location of Laboratory (Building, Floor, Suite
if applicable.) Fee Coupon/Certificate will be mailed to this Address unless
mailing or corporate address is specified
NUMBER, STREET (No P.O. Boxes)
MAILING/BILLING ADDRESS (If different from facility address) send Fee Coupon
or certificate
NUMBER, STREET
CITY STATE ZIP CODE CITY STATE ZIP CODE
SEND FEE COUPON TO THIS ADDRESS
Physical
Mailing
Corporate
SEND CERTIFICATE TO THIS ADDRESS
Physical
Mailing
Corporate
CORPORATE ADDRESS
(If different from facility) send Fee Coupon or certificate
NUMBER, STREET
NAME OF DIRECTOR
(Last, First, Middle Initial) CITY STATE ZIP CODE
CREDENTIALS
FOR OFFICE USE ONLY
Date Received
II. TYPE OF CERTIFICATE REQUESTED (Check only one) Please refer to the accompanying instructions for inspection and
certificate testing requirements)
Certificate of Waiver (Complete Sections I – VI and IX – X)
Certificate for Provider Performed Microscopy Procedures (PPM) ((Complete Sections I-VII and IX-X)
Certificate of Compliance (Complete Sections I – X)
Certificate of Accreditation (Complete Sections I – X) and indicate which of the following organization(s) your
laboratory is accredited by for CLIA purposes, or for which you have applied for accreditation for CLIA purposes.
The Joint Commission AAHHS/HFAP AABB A2LA
CAP COLA ASHI
If you are applying for a Certificate of Accreditation, you must provide evidence of accreditation for your laboratory by an
approved accreditation organization as listed above for CLIA purposes or evidence of application for such accreditation within
11 months after receipt of your Certificate of Registration.
NOTE: Laboratory directors performing non-waived testing (including PPM) must meet specific education, training and
experience under subpart M of the CLIA regulations. Proof of these qualifications for the laboratory director must be submitted
with this application.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0581. Expiration Date: 3/31/2021. The time required to complete this information
collection is estimated to average one hour per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS
Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact
LabExcellence@cms.hhs.gov.
Form CMS-116 (09/17)
Form CMS-116 (09/17) 2
NAME AND ADDRESS/LOCATION TESTS PERFORMED/SPECIALTY/SUBSPECIALTY
NAME OF LABORATORY OR HOSPITAL DEPARTMENT
ADDRESS/LOCATION (Number, Street, Location if applicable)
CITY, STATE, ZIP CODE
TELEPHONE NO. (Include area code)
NAME OF LABORATORY OR HOSPITAL DEPARTMENT
ADDRESS/LOCATION (Number, Street, Location if applicable)
CITY, STATE, ZIP CODE TELEPHONE NO. (Include area code)
III. TYPE OF LABORATORY (Check the one most descriptive of facility type)
01 Ambulance 11 Health Main. Organization 22 Practitioner Other (Specify)
02 Ambulatory Surgery Center 12 Home Health Agency
03 Ancillary Testing Site in 13 Hospice
23 Prison
Health Care Facility
14 Hospital
24 Public Health Laboratories
04 Assisted Living Facility
15 Independent
25 Rural Health Clinic
05 Blood Bank
16 Industrial
26 School/Student Health Service
06 Community Clinic
17 Insurance
27 Skilled Nursing Facility/
07 Comp. Outpatient Rehab Facility
18 Intermediate Care Facilities for
Nursing Facility
08 End Stage Renal Disease Individuals with Intellectual
28 Tissue Bank/Repositories
Dialysis Facility Disabilities
29 Other (Specify)
09 Federally Qualified 19 Mobile Laboratory
Health Center
20 Pharmacy
10 Health Fair
21 Physician Office
IV. HOURS OF LABORATORY TESTING (List times during which laboratory testing is performed in HH:MM format) If testing 24/7 Check Here
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
FROM:
TO:
(For multiple sites, attach the additional information using the same format.)
V. MULTIPLE SITES (must meet one of the regulatory exceptions to apply for this provision in 1-3 below)
Are you applying for a single site CLIA certificate to cover multiple testing locations?
No. If no, go to section VI. Yes. If yes, complete remainder of this section.
Indicate which of the following regulatory exceptions applies to your facility’s operation.
1. Is this a laboratory that is not at a fixed location, that is, a laboratory that moves from testing site to testing site, such as
mobile unit providing laboratory testing, health screening fairs, or other temporary testing locations, and may be covered
under the certificate of the designated primary site or home base, using its address?
Yes No
If yes and a mobile unit is providing the laboratory testing, record the vehicle identification number(s) (VINs) and attach to the
application.
2. Is this a not-for-profit or Federal, State or local government laboratory engaged in limited (not more than a combination of 15
moderate complexity or waived tests per certificate) public health testing and filing for a single certificate for
multiple sites?
Yes No
If yes, provide the number of sites under the certificate and list name, address and test performed for each
site below.
3. Is this a hospital with several laboratories located at contiguous buildings on the same campus within the same physical
location or street address and under common direction that is filing for a single certificate for these locations?
Yes No
If yes, provide the number of sites under this certificate and list name or department, location within
hospital and specialty/subspecialty areas performed at each site below.
If additional space is needed, check here and attach the additional information using the same format.
Form CMS-116 (09/17) 3
In the next three sections, indicate testing performed and annual test volume.
VI. WAIVED TESTING If only applying for a Certificate of Waiver, complete this section and skip sections VII (PPM Testing) and VIII
(Non-Waived Testing).
Identify the waived testing (to be) performed. Be as specific as possible. This includes each analyte test system or device used in
the laboratory.
e.g. (Rapid Strep, Acme Home Glucose Meter)
Indicate the ESTIMATED TOTAL ANNUAL TEST volume for all waived tests performed ________________
Check if no waived tests are performed
and attach additional information using the same format.If additional space is needed, check here
VII. PPM TESTING If only applying for a Certificate for PPM, complete this section and skip section VIII (Non-Waived Testing).
Identify the PPM testing (to be) performed. Be as specific as possible.
e.g. (Potassium Hydroxide (KOH) Preps, Urine Sediment Examinations)
Indicate the ESTIMATED TOTAL ANNUAL TEST volume for all PPM tests performed ________________
If also performing waived complexity tests, complete Section VI. For laboratories applying for certificate of compliance or
certificate of accreditation, also include PPM test volume in the specialty/subspecialty category and the “total estimated annual
test volume” in section VIII.
Check if no PPM tests are performed
If additional space is needed, check here
and attach additional information using the same format.
4
VIII. NON-WAIVED TESTING (Including PPM testing if applying for a Certificate of Compliance or Accreditation) Complete this section only
if you are applying for a Certificate of Compliance or a Certificate of Accreditation.
Identify the non-waived testing (to be) performed. Be as specific as possible. This includes each analyte test system or device
used in the laboratory e.g. (Potassium, Acme Chemistry Analyzer).
If additional space is needed, check here
and attach additional information using the same format.
If you perform testing other than or in addition to waived tests, complete the information below. If applying for one certificate
for multiple sites, the total volume should include testing for ALL sites.
Place a check (3) in the box preceding each specialty/subspecialty in which the laboratory performs testing. Enter the
estimated annual test volume for each specialty. Do not include testing not subject to CLIA, waived tests, or tests run for
quality control, calculations, quality assurance or proficiency testing when calculating test volume. (For additional guidance on
counting test volume, see the instructions included with the application package.)
If applying for a Certificate of Accreditation, indicate the name of the Accreditation Organization beside the applicable specialty/
subspecialty for which you are accredited for CLIA compliance. (The Joint Commission, AOA, AABB, A2LA ,CAP, COLA or ASHI)
SPECIALTY /
SUBSPECIALTY
ACCREDITING
ORGANIZATION
ANNUAL
TEST VOLUME
SPECIALTY /
SUBSPECIALTY
ACCREDITING
ORGANIZATION
ANNUAL
TEST
VOLUME
HISTOCOMPATIBILITY 010 HEMATOLOGY 400
Transplant Hematology
Nontransplant
IMMUNOHEMATOLOGY
MICROBIOLOGY
ABO Group & Rh Group 510
Bacteriology 110 Antibody Detection (transfusion) 520
Mycobacteriology 115 Antibody Detection (nontransfusion) 530
Mycology 120 Antibody Identification 540
Parasitology 130 Compatibility Testing 550
Virology 140
PATHOLOGY
DIAGNOSTIC IMMUNOLOGY
Histopathology 610
Syphilis Serology 210 Oral Pathology 620
General Immunology 220 Cytology 630
CHEMISTRY RADIOBIOASSAY 800
Routine 310 Radiobioassay
Urinalysis 320
CLINICAL CYTOGENETICS 900
Endocrinology 330 Clinical Cytogenetics
Toxicology 340
TOTAL ESTIMATED ANNUAL TEST VOLUME:
Form CMS-116 (09/17)
5
IX. TYPE OF CONTROL (check the one most descriptive of ownership type)
VOLUNTARY NONPROFIT
01 Religious Affiliation
02 Private Nonprofit
03 Other Nonprofit
(Specify)
FOR PROFIT
04 Proprietary
GOVERNMENT
05 City
06 County
07 State
08 Federal
09 Other Government
(Specify)
X. DIRECTOR AFFILIATION WITH OTHER LABORATORIES
If the director of this laboratory serves as director for additional laboratories that are separately certified, please
complete the following:
CLIA NUMBER NAME OF LABORATORY
ATTENTION: READ THE FOLLOWING CAREFULLY BEFORE SIGNING APPLICATION
Any person who intentionally violates any requirement of section 353 of the Public Health Service Act as amended
or any regulation promulgated thereunder shall be imprisoned for not more than 1 year or fined under title
18, United States Code or both, except that if the conviction is for a second or subsequent violation of such a
requirement such person shall be imprisoned for not more than 3 years or fined in accordance with title 18,
United States Code or both.
Consent: The applicant hereby agrees that such laboratory identified herein will be operated in accordance with
applicable standards found necessary by the Secretary of Health and Human Services to carry out the purposes of
section 353 of the Public Health Service Act as amended. The applicant further agrees to permit the Secretary, or
any Federal officer or employee duly designated by the Secretary, to inspect the laboratory and its operations and
its pertinent records at any reasonable time and to furnish any requested information or materials necessary to
determine the laboratory’s eligibility or continued eligibility for its certificate or continued compliance with CLIA
requirements.
PRINT NAME OF OWNER/DIRECTOR OF LABORATORY
SIGNATURE OF OWNER/DIRECTOR OF LABORATORY (Sign in ink) DATE
NOTE: Completed 116 applications must be sent to your local State Agency. Do not send any payment with your
completed 116 application.
STATE AGENCY CONTACT INFORMATION CAN BE FOUND AT:
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf
Form CMS-116 (09/17)
THE CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION
(FORM CMS-116)
INSTRUCTIONS FOR COMPLETION
CLIA requires every facility that tests human specimens
for the purpose of providing information for the
diagnosis, prevention or treatment of any disease or
impairment of, or the assessment of the health of, a
human being to meet certain Federal requirements.
If your facility performs tests for these purposes, it is
considered, under the law, to be a laboratory. Facilities
only collecting or preparing specimens (or both) or
only serving as a mailing service are not considered
laboratories. CLIA does not apply to a facility that only
performs forensic testing. CLIA applies even if only one
or a few basic tests are performed, and even if you are
not charging for testing. In addition the CLIA legislation
requires financing of all regulatory costs through fees
assessed to affected facilities.
The CLIA application (Form CMS-116) collects
information about your laboratory’s operation which
is necessary to determine the fees to be assessed, to
establish baseline data and to fulfill the statutory
requirements for CLIA. This information will also provide
an overview of your facility’s laboratory operation. All
information submitted should be based on your facility’s
laboratory operation as of the date of form completion.
NOTE: WAIVED TESTS ARE NOT EXEMPT FROM
CLIA. FACILITIES PERFORMING ONLY THOSE TESTS
CATEGORIZED AS WAIVED MUST APPLY FOR A CLIA
CERTIFICATE OF WAIVER.
NOTE: Laboratory directors performing non-waived
testing (including PPM) must meet specific education,
training and experience under subpart M (42 CFR
PART 493) of the CLIA requirements. Proof of these
requirements for the laboratory director must be
submitted with the application. Information to be
submitted with the application include:
• Verification of State Licensure, as applicable
• Documentation of qualifications:
• Education (copy of Diploma, transcript from
accredited institution, CMEs),
• Credentials, and
• Laboratory experience.
Individuals who attended foreign schools must have an
evaluation of their credentials determining equivalency
of their education to education obtained in the United
States. Failure to submit this information will delay the
processing of your application.
ALL APPLICABLE SECTIONS MUST BE COMPLETED.
INCOMPLETE APPLICATIONS CANNOT BE PROCESSED
AND WILL BE RETURNED TO THE FACILITY. PRINT
LEGIBLY OR TYPE INFORMATION.
I. GENERAL INFORMATION
date of the change. For all other changes, including
change in location, director, lab closure, etc., check
“other changes” and provide the effective date of the
change.
CLIA Identification Number: For an initial applicant, the
CLIA number should be left blank. The number will be
assigned when the application is processed. For all other
applicants, enter the 10 digit CLIA identification number
already assigned and listed on your CLIA certificate.
Facility Name: Be specific when indicating the name of
your facility, particularly when it is a component of a
larger entity, e.g., respiratory therapy department in XYZ
Hospital. For a physician’s office, this may be the name
of the physician. NOTE: the information provided is what
will appear on your certificate.
Physical Facility Address: This address is mandatory and
must reflect the physical location where the laboratory
testing is performed. The address may include a floor,
suite and/or room location, but cannot be a Post Office
box or Mail Stop.
If the laboratory has a separate mailing and/or corporate
address (from the Facility Address), please complete the
appropriate sections on the form.
Mailing Address: This address is optional and may be
used if the laboratory wants to direct the mailing of the
CLIA fee coupon and/or CLIA certificate to an alternate
location, such as an accounts payable office. A Post Office
box number or Mail Stop number may be used as part of
the Mailing Address for this section.
Corporate Address: This address is optional and may
be used if the laboratory wants to direct the mailing of
the CLIA fee coupon and/or CLIA certificate to another
location, such as, the main headquarters or home office
for the laboratory. A Post Office box number or Mail
Stop number may be used as part of the Corporate
Address for this section.
Form Mailing: Select the address (Physical, Mailing,
Corporate) where the CLIA fee coupon and CLIA
certificate are to be mailed.
For Office Use Only: The date received is the date the
form is received by the state agency or CMS regional
office for processing.
II. TYPE OF CERTIFICATE REQUESTED
Select your certificate type based on the highest level
of test complexity performed by your laboratory. A
laboratory performing non-waived tests can choose
Certificate of Compliance or Certificate of Accreditation
based on the agency you wish to survey your laboratory.
When completing this section, please remember that a
facility holding a: Certificate of Waiver can only perform
tests categorized as waived;*
For an initial applicant, check “initial application”. For
• Certificate for Provider Performed Microscopy
an initial survey or for a recertification, check “survey”.
Procedures (PPM) can only perform tests categorized
For a request to change the type of certificate, check
as PPM, or tests categorized as PPM and waived
“change in certificate type” and provide the effective
tests;*
Form CMS-116 (09/17) Instructions
VI. WAIVED TESTING
VII. PPM TESTING
VIII. NON-WAIVED TESTING (INCLUDING PPM)
IX. TYPE OF CONTROL
X. DIRECTOR OF ADDITIONAL LABORATORIES
• Certificate of Compliance can perform tests
categorized as waived, PPM and moderate and/or
high complexity tests provided the applicable CLIA
quality standards are met following a CLIA survey;
and
• Certificate of Accreditation can perform tests
categorized as waived, PPM and moderate and/
or high complexity non-waived tests provided the
laboratory is currently accredited by an approved
accreditation organization. (If your CMS-approved
accreditation organization is not listed, contact your
local State Agency for further instructions.)
*A current list of waived and PPM tests may be
obtained from your State agency. Specific test system
categorizations can also be found on the Internet at:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/
cfCLIA/clia.cfm.
III. TYPE OF LABORATORY
Select the type that is most descriptive of the location
where the laboratory testing is performed.
If selecting ‘mobile laboratory’ (code 19), a mobile
laboratory is defined as a movable, self-contained
operational laboratory with its own personnel,
equipment, and records. For record keeping purposes,
include, on a separate sheet of paper, the vehicle
identification numbers (VINs) of all vehicles used for
mobile laboratory testing.
If selecting ‘Practitioner Other’ (code 22), this type
includes practitioners such as, dentists, chiropractors, etc.
IV. HOURS OF ROUTINE OPERATION
Provide only the times when actual laboratory testing
is performed in your facility. Please use the HH:MM
format and check box marked ‘24/7’ if laboratory testing
is performed continuously, e.g., 24 hours a day, 7 days a
week. Do not use military time.
V. MULTIPLE SITES
You can only qualify for the multiple site provision
(more than one site under one certificate) if you meet
one of the CLIA requirements described in 42 CFR 493.
493.35(b)(1-3), 493.43(b)(1-3) and 493.55(b)(1-3)
Hospice and HHA could qualify for an exception.
Indicate the estimated total annual test volume for all
waived tests performed. List can be found at:
http:www.cms.gov/CLIA/downloads/waivetbl.pdf
Indicate the estimated total annual test volume for all
PPM tests performed. List can be found at:
https://www.cms.gov/Regulations-and-Guidance/
Legislation/CLIA/Downloads/ppmplist.pdf
The total Estimated Annual Test volume in this section
includes all non-waived testing, including PPM tests
previously counted in section VII. Follow the specific
instructions on page 3 of the Form CMS-116 when
completing this section for test counting information.
(Note: The Accrediting Organization column should
reflect accreditation information for CLIA purposes onl
e.g., CAP, etc.).
y;
Select the type of ownership or control which most
appropriately describes your facility.
List all other facilities for which the director is
responsible and that are under different certificates.
Note that for a Certificate of PPM, Certificate of
Compliance or Certificate of Accreditation, an individu
can only serve as the director for no more than five
certificates.
al
Reminders - Before submitting the Form CMS-116:
1. Include the current or estimated annual test volume.
2. For Certificate for PPM, Certificate of Compliance, or Certificate of Accreditation, include the laboratory director
qualifications.
3. Do not send any money with your application.
4. Send the completed Form CMS-116 to the appropriate State Agency (http://www.cms.gov/Regulations-and-Guidance/
Legislation/CLIA/Downloads/CLIASA.pdf).
Once the completed Form CMS-116 has been returned to the applicable State agency and it is processed, a fee remittance
coupon will be issued. The fee remittance coupon will indicate your CLIA identification number and the amount due for the
certificate, and if applicable the compliance (survey) or validation fee. If you are applying for a Certificate of Compliance or
Certificate of Accreditation, you will initially pay for and receive a Registration Certificate. A Registration Certificate permits a
facility requesting a Certificate of Compliance to perform testing until an onsite inspection is conducted to determine program
compliance; or for a facility applying for a Certificate of Accreditation, until verification of accreditation by an approved
accreditation organization is received by CMS.
If you need additional information concerning CLIA, or if you have questions about completion of this form, please contact your
State agency. State agency contact information can be found at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf
Form CMS-116 (09/17) Instructions
VIII. NON-WAIVED TESTING
TESTS COMMONLY PERFORMED AND THEIR CORRESPONDING
LABORATORY SPECIALTIES/SUBSPECIALITIES
HISTOCOMPATIBILITY (010)
HLA Typing (disease associated antigens)
MICROBIOLOGY
Bacteriology (110)
Gram Stain
Culture
Susceptibility
Strep screen
Antigen assays (H.pylori, Chlamydia, etc.)
Mycobacteriology (115)
Acid Fast Smear
Mycobacterial culture
Mycobacterial susceptibility
Mycology (120)
Fungal Culture
DTM
KOH Preps
Parasitology (130)
Direct Preps
Ova and Parasite Preps
Wet Preps
Virology (140)
RSV (Not including waived kits)
HPV assay
Cell culture
DIAGNOSTIC IMMUNOLOGY
Syphilis Serology (210)
RPR
FTA, MHATP
General Immunology (220)
Allergen testing
ANA
Antistreptolysin O
Antigen/Antibody (hepatitis, herpes, rubella, etc.)
Complement (C3, C4)
Immunoglobulin
HIV
Mononucleosis assay
Rheumatoid factor
Tumor marker (AFP, CA 19-9, CA 15-3, CA 125)*
*Tumor markers can alternatively be listed under
Routine Chemistry instead of General Immunology.
HEMATOLOGY (400)
Complete Blood Count (CBC)
WBC count
RBC count
Hemoglobin
Hematocrit (Not including spun micro)
Platelet count
Differential
Activated Clotting Time
Prothrombin time (Not including waived instruments)
Partial thromboplastin time
Fibrinogen
Reticulocyte count
Manual WBC by hemocytometer
Manual platelet by hemocytometer
Manual RBC by hemocytometer
Sperm count
IMMUNOHEMATOLOGY
ABO group (510)
Rh(D) type (510)
Antibody screening
Antibody identification (540)
Compatibility testing (550)
PATHOLOGY
Dermatopathology
Oral Pathology (620)
PAP smear interpretations (630)
Other Cytology tests (630)
Histopathology (610)
RADIOBIOASSAY (800)
Red cell volume
Schilling test
CLINICAL CYTOGENETICS (900)
Fragile X
Buccal smear
Prader-Willi syndrome
FISH studies for: neoplastic disorders, congenital disorders
or solid tumors.
Form CMS-116 (09/17) Instructions
CHEMISTRY
Routine Chemistry (310)
Albumin
Ammonia
Alk Phos
ALT/SGPT
AST/SGOT
Amylase
Bilirubin
Blood gas (pH, pO2, pCO2)
BUN
Calcium
Chloride
Cholesterol
Cholesterol, HDL
CK/CK isoenzymes
CO2
Creatinine
Ferritin
Folate
GGT
Glucose (Not fingerstick)
Iron
LDH/LDH isoenzymes
Magnesium
Potassium
Protein, electrophoresis
Protein, total
PSA
Sodium
Triglycerides
Troponin
Uric acid
Vitamin B12
Endocrinology (330)
Cortisol
HCG (serum pregnancy test)
T3
T3 Uptake
T4
T4, free
TSH
Toxicology (340)
Acetaminophen
Blood alcohol
Blood lead (Not waived)
Carbamazepine
Digoxin
Ethosuximide
Gentamicin
Lithium
Phenobarbital
Phenytoin
Primidone
Procainamide
NAPA
Quinidine
Salicylates
Theophylline
Tobramycin
Therapeutic Drug Monitoring
Urinalysis** (320)
Automated Urinalysis (Not including waived instruments)
Microscopic Urinalysis
Urine specific gravity by refractometer
Urine specific gravity by urinometer
Urine protein by sulfosalicylic acid
** Dipstick urinalysis is counted in Section VI. WAIVED TESTING
NOTE: This is not a complete list of tests covered by CLIA. Other non-waived tests and their specialties/ subspecialties
can be found at http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/SubjecttoCLIA.pdf
and http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/lccodes.pdf. You may also call
your State agency for further information. State agency contact information can be found at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf.
Form CMS-116 (09/17) Instructions
GUIDELINES FOR COUNTING TESTS FOR CLIA
• For histocompatibility, each HLA typing (including disease associated antigens), HLA antibody screen, or HLA
crossmatch is counted as one test.
• For microbiology, susceptibility testing is counted as one test per group of antibiotics used to determine
sensitivity for one organism. Cultures are counted as one per specimen regardless of the extent of
identification, number of organisms isolated and number of tests/procedures required for identification.
• For general immunology, testing for allergens should be counted as one test per individual allergen.
• For hematology, each measured individual analyte of a complete blood count or flow cytometry test that is
ordered and reported is counted separately. The WBC differential is counted as one test.
• For immunohematology, each ABO, Rh, antibody screen, crossmatch or antibody identification is counted as
one test.
• For histopathology, each block (not slide) is counted as one test. Autopsy services are not included. For
those laboratories that perform special stains on histology slides, the test volume is determined by adding
the number of special stains performed on slides to the total number of specimen blocks prepared by
the laboratory.
• For cytology, each slide (not case) is counted as one test for both Pap smears and nongynecologic cytology.
• For clinical cytogenetics, the number of tests is determined by the number of specimen types processed on each
patient; e.g., a bone marrow and a venous blood specimen received on one patient is counted as
two tests.
• For chemistry, each analyte in a profile counts as one test.
• For urinalysis, microscopic and macroscopic examinations, each count as one test. Macroscopics (dipsticks) are
counted as one test regardless of the number of reagent pads on the strip.
• For all specialties/subspecialities, do not count calculations (e.g., A/G ratior, MCH, T7, etc.), quality control,
quality assurance, or proficiency testing assays.
If you need additional information concerning counting tests for CLIA, please contact your State agency.
Form CMS-116 (09/17)
Instructions
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Form Approved: CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION (Medicare & Medicaid)

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Completed 14 July 2020

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