TX HHS Form 3225. Application for Certification Supplement to CMS 116

The TX HHS Form 3225, Application for Certification Supplement to CMS 116, is a crucial document that helps laboratories obtain certification under the Clinical Laboratory Improvement Amendments (CLIA). This form serves as a supplement to completing Centers for Medicare & Medicaid Services Form CMS 116 and provides additional information required for laboratory certification.

This application requires identifying information about the laboratory, including its name, CLIA number, federal tax ID number, area code, phone number, and fax number. The form also asks for disclosure of ownership, listing names, addresses, or employer identification numbers (EIN) for individuals or organizations having direct or indirect ownership of a controlling interest in the entity.

To complete this application, laboratories must provide detailed information about their ownership structure, including the type of entity and the names and addresses of directors if the disclosing entity is a corporation. By filling out this form, laboratories can ensure compliance with CLIA regulations and obtain the necessary certification to operate legally. Key points to note include:

• The application is used by clinical laboratories seeking certification under CLIA.
• The form requires identifying information about the laboratory and its ownership structure.
• The application serves as a supplement to completing Centers for Medicare & Medicaid Services Form CMS 116.