Deliverable preview
See how a WaivedLab filing packet is organized.
This in-browser sample shows the structure, checkpoints, and supporting tables a client may receive. The exact documents depend on the clinic, state, filing route, and accepted scope.
Sample only
Entirely fictitious, redacted, and not valid for filing.
“Sample Wellness Clinic LLC,” every person, address, identifier, device entry, date, and status below is invented or visibly redacted. This is not a completed CMS-116, not a client record, not proof of eligibility, and not an agency-approved packet. No patient information is used or needed.
Open a prepared CMS-116 sample.
This downloadable copy uses the actual CMS form with fictional facility and test entries. Review how the fields are populated. Tax ID, dates, signatures, exact-device verification and other unresolved facts remain blank or pending. Every page is marked as a sample.
Download fictional CMS-116 sample (PDF)10 pages · editable form fields · no real applicant information · not a filing-ready packet
Packet cover + control sheet
One page that identifies the case, included documents, open items, and who must act next.
Applicant
[FICTITIOUS] Sample Wellness Clinic LLC
Location
[REDACTED SAMPLE ADDRESS], Texas
Proposed workflow
Point-of-care testing performed onsite
Packet status
DRAFT — CLIENT REVIEW REQUIRED
Current checkpoint
Client must verify every fact, confirm exact test systems, resolve highlighted questions, and sign the applicable agency form. WaivedLab has no submission authorization at this stage.
Application field map
A review-friendly summary that maps intake facts to the applicable application before signature.
| Application area | Sample entry | Review status |
|---|---|---|
| Facility name | Sample Wellness Clinic LLC | Client to confirm |
| Physical address | [REDACTED SAMPLE ADDRESS] | Client to confirm |
| Certificate type | Certificate of Waiver | Route to confirm |
| Testing start date | [SAMPLE DATE] | Client to confirm |
| Ownership / responsible parties | [FICTIONAL / REDACTED] | Signature required |
In a live engagement, the actual agency form—not this sample table—is included for the client's line-by-line review and signature.
Planned test-system verification table
The analyte alone is not enough. Each exact manufacturer, model, and intended use must be checked.
Analyte or test
[SAMPLE ANALYTE]
Manufacturer
[NOT YET CONFIRMED]
Exact system / model
[NOT YET CONFIRMED]
Specimen + intended use
[CLIENT CLARIFICATION NEEDED]
Human review
PENDING
Client text is not verification.
Evidence reference
[NONE RETAINED YET]
Analyte or test
[SAMPLE ANALYTE 2]
Manufacturer
[FICTIONAL MANUFACTURER]
Exact system / model
[FICTIONAL DEVICE]
Catalog identifier
[FICTIONAL ID]
Human review
VERIFY AGAINST CURRENT OFFICIAL EVIDENCE
Reviewer + date
[NOT REVIEWED]
A test name, category, or marketing description does not establish waived status. A live packet must use the exact test system and current official sources.
State routing + fee checklist
A concise list of the applicable manual filing channel, required state forms or applications, fees, and items that still need confirmation.
- Federal or CLIA-exempt state route identified for the clinic location
- Current agency contact and official filing instructions linked
- Known federal and state fees separated from the WaivedLab service fee
- Additional state forms, applications, licenses, or registrations listed when applicable
- Processing estimates labeled as agency estimates—not promises
Sample status: routing illustration only. Official instructions and current fees must be reconfirmed for the real clinic immediately before filing.
Signature + authorization gate
Two distinct client controls prevent an inquiry, payment, signature, or unfinished draft from becoming a submission.
Gate A
Review and signature
The authorized clinic representative verifies the packet and signs the agency form. WaivedLab never signs on the applicant's behalf.
Gate B
Manual sender + authorization
The written scope identifies who sends the signed packet through the required manual channel. Any transmission requires separate written authorization tied to the exact packet version, file hash, destination, and channel.
Submission + follow-up log
After authorization, the operational record shows what was sent, by which person, where it went, the transmission evidence, and what happens next.
Correction + change log
The record distinguishes included corrections to the same initial application from a later operational change that requires a new written scope.
Initial-application correction
Reasonable clarification or agency-requested revision
Included in the confirmed initial scope; the client reviews and reauthorizes a changed packet.
Later operational change
Owner, location, director, contact information, or test system
A separate service reviewed and quoted before work begins.
Every item records who requested it, when, how it was classified, who must act next, and the evidence of resolution. No retroactive or surprise charge is created by this log.