CERTIFICATE #:___ LICENSE#:___
State of
AGENCY FOR HEALTH CARE ADMINISTRATION
DIVISION OF HEALTH QUALITY ASSURANCE
CLINICAL LABORATORY
This is to confirm that _____________ has complied with Chapter ***,
Statute, and with Chapter ***,
Administrative Code,and is authorized to operate the following laboratory in the
specialties or sub specialties of:
Bacteriology, Diagnostic Immunology, Hematology, Routine Chemistry, Toxicology
EFFECTIVE DATE: ________
EXPIRATION DATE: _________
___________________________________________
Deputy Secretary Division of Health Quality Assurance
