LIST OF TESTS PERFORMED including Waived and PPM LAB NAME ADDRESS CITYZIP CLIA NO CERTIFICATE TYPE Please list the manufacturer146s name and model of the instrument or manufacturer146s name o ID: 886822
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1 STATE OF NEBRASKA – ONLY FOR LABORA
STATE OF NEBRASKA – ONLY FOR LABORATORIES LOCATED IN NEBRASKA LIST OF TESTS PERFORMED (including Waived and PPM) LAB NAME ____________________________________________________________________________________ ADDRESS ________________________________________ CITY/ZIP ___________________________________ CLIA NO. _______________ CERTIFICATE TYPE* _______________________________________________ Please list the manufacturer’s name and model of the instrument or manufacturer’s name of the test kit used for patient testing. For example, do not list “Hematology machine or Strep Kit”. This will ensure tha you will receive the correct certificate based on the tests performed in your laboratory. TEST METHOD SPECIALTY/SUBSPECIALTY ANNUAL VOLUME