Testing Certificate Template

Testing Certificate Template

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

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