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Facility Amendment and Notification of Change

Facility Amendment

Operators submit an amendment request when there is

  • a change or addition to laboratory services
  • a change to limits or conditions
  • an extension or renewal of a time-limited approval

Please email your request to

Notification of Change

A notification of change is required when there is

  • a change in medical directorship and/or laboratory physician staff (facility or regional)
  • a change in operator contact information
  • a change in hours of operation
  • an addition or removal of a bed and/or phlebotomy chair
  • a withdrawal of operational services (categories or tests)
  • a temporary or permanent closure of a laboratory or specimen collection facility
  • an addition or cancellation of a payment number
  • a change in specimen collection station’s receiving and testing laboratory
  • a change in shareholder and/or ownership percentages (< 10% shares)

Supporting Documents

(If the form does not open, right-click the form link above, select ‘save link as’ or ‘save target as’ and save the file prior to editing. If problems persist, please contact

Please submit the conflict of interest declaration and notification of change form via the secure upload tool

(As of July 1, 2020, the new upload tool works best with the latest version of Google Chrome. Please update your bookmarks.)

SOURCE: Facility Amendment and Notification of Change ( )
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