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10 RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF HEALTH CARE SERVICES STEVE ARWOOD DIRECTOR June 19, 2014 Amerathon, LLC dba American Health Associate Country Club Drive Suite C-30 Farmington Hills, MI Dear Director: RE: CLIA #23D On June 18, 2014, we received a CMS-116 CLIA Application from you requesting the changes listed below. These changes were entered into the CMS database on June 19, Previous Data Facility Name: Suburban Medical Laboratory, Inc dba Medlab Current Data Amerathon, LLC dba American Health Associate Federal tax i.d.#: Mailing Address: N/A 671 Ohio Pike Suite K Cincinnati, OH Your current CLIA Certificate of Compliance is valid through May 23, Please contact this office at (517) should you have further questions. For additional information about CLIA topics, please go to: Sincerely, Michelle Roepke, BS, MT(ASCP) Manager - Laboratory Improvement Section Division of Licensing and Certification LARA Bureau of Health Care Services LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 611 W. Ottawa P.O. BOX LANSING, MICHIGAN (517)
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15 October 15, 2014 Denise Kamps, Director Amerathon, Llc 521 E County Line Rd Greenwood, IN CLIA# 15D Dear Director: This letter is to confirm receipt of correspondence and/or information dated October 1, 2014 regarding the following change(s) within your laboratory: Current Name: Amerathon, LLC DBA American Health Associate Current Tax ID: Current Telephone No.: (317) Current Fax No.: (317) The above change(s) have been made in the CLIA database. While we do appreciate the notification and information submitted, the Indiana State Department of Health (ISDH) does not have administrative authority to issue a new CLIA certificate at this time for the changes made, i.e., name, laboratory director, address, etc. Please use this letter as verification of your change. FOR FUTURE CHANGES ONLY: Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 and Enclosure I for the following changes: 1. Status or Certificate Change (6 months after termination of certificate) 2. Reinstatement of CLIA Certificate 3. Change of director for Provider Performed Microscopy Procedure (PPM) Certificates, and Certificate of Compliance (Also include qualification information for the director: license, diploma, transcripts, board certification, additional training, etc) Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 and Enclosure A for the following changes: 1. Change of Ownership
16 2. Change of Tax ID Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 for the following changes: 1. Multi site exception (for not for profit status request you must provide documentation of not for profit status for each location. 2. Specialty/ Subspecialty change for Certificate of Compliance. (For Certificate of Accreditation please notify your Accreditation Organization.) Please notify this office by submitting a letter on your letter head and signed by your director, that includes your CLIA number and the name of your facility for the following changes: 1. Change of Director Certificate of Waiver 2. Change of Director Certificate of Accreditation (must also include approval of director change from your Accreditation Organization.) 3. Status Change to Certificate of Waiver 4. Change of Name of Laboratory 5. Change of Location (Physical Address and Mailing Address) 6. Total Volume Change 7. Telephone and fax number change 8. Reinstatement of certificate (within 6 months of termination) 9. Change in Accreditation Organization (with approval letter from new Accreditation Organization) 10. Voluntary Closure/Termination of CLIA Certificate 11. Personnel changes- Technical Supervisor for Certificate of Compliance If you have any questions, require any forms, or need further information, please address your concerns in to lswitzer@isdh.in.gov or feel free to call (317) or the numbers below or visit our web site at Sincerely yours, Lorraine Switzer Program Director CLIA/Blood Ctr/Rehab/Portable X-Ray Programs Acute Care Division Indiana State Department of Health (317) (317) Fax
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