Waived HIV/AIDS-Related Testing

WV AIDS-Related Testing Facilities: Waived
Is this an initial or renewal application?*

Initial application for 2025Renewal application for 2025Initial application for 2026Renewal application for 2026
Certification Year
Are you currently performing HIV testing?*

Yes, we perform HIV testing on-site.No, we only collect specimens and send them to a laboratory for testing.
Do you plan on performing HIV testing in the future?*

YesNo
You are not required to obtain WV HIV/AIDS-Related Testing Certification. If you continue the application process, you acknowledge that any payments made are nonrefundable. If you have any questions about this message, please email us at DHOLSHIV@wv.gov before proceeding.
Date you anticipate to begin performing HIV testing. *

MonthDayYear
Date
Laboratory and CLIA Information
Except for capitalization, enter the data in this section EXACTLY as it appears on your CLIA certificate (example below). Please do not use CAPS unless it is appropriate (e.g. LLC).

If the information on your certificate is outdated or incorrect, please do not proceed with this application until the information has been updated!
- If your laboratory has a Certificate of Compliance, contact WV CLIA to make any necessary changes.
- If your laboratory is Accredited and you are changing the laboratory director, please notify your Accrediting Organization. For all other changes, contact WV CLIA.
WV CLIA can be reached at DHOLSCLIA@wv.gov.
Facility Name*
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code (5 digits only)
CLIA Number*
Upload a PDF copy of your active CLIA certificate. If you do not have a PDF copy, please download one from the QCOR lookup tool. Links to QCOR and instructions are provided below.*

Browse Files

Cancelof
You may access the QCOR lookup tool at https://qcor.cms.gov/index_new.jsp.

Instructions for accessing QCOR can be found at https://tinyurl.com/Access-QCOR.
Laboratory Director Name*

First NameLast Name
Laboratory Director Credentials*
Credentials, if "Other"*
Contact Information
The email address for Contact 1 must be verified before this application can be submitted to ensure your documents are delivered successfully. Enter the address and click the "verify email address" button. A validation code will be emailed. Copy the code from the email, paste it into the box, and select "confirm code." If the email address was initially entered incorrectly, select "reset email" and start over.

Note that documents will be sent to both contacts, but Contact 2's email is not being verified. Please ensure that it is entered correctly before submitting the application.

Please do not use CAPS when entering contact information.
Contact 1 Name*

First NameLast Name
Contact 1 Email*
Contact 1 email transfer
example@example.com
Contact 1 Phone*
Contact 2 Name*

First NameLast Name
Contact 2 Email*
example@example.com
Contact 2 Phone*

Multiple Site Exceptions
Do you currently or plan to perform HIV testing at multiple locations under this certificate? Multiple locations include temporary testing and mobile testing.*

YesNo
Where does/will additional testing occur? Select all that apply.*

Temporary location, such as a health fairFixed location other than the main physical locationMobile location (inside of a vehicle)
We will verify whether your CLIA certificate has a multiple site exception to perform testing in other locations and will contact you if further attention is required.
For more information on this topic, click HERE to view CMS clarification and examples.

	Plan to Perform
Abbott/Alere Determine
Chembio DPP HIV 1/2
Chembio DPP HIV-Syphilis combo
Chembio STAT-PAK
Chembio Sure Check
Clearview COMPLETE
Clearview STAT-PAK
INSTI HIV-1 antibody
INSTI HIV-1/2 antibody
OraQuick rapid HIV-1/2 antibody
Trinity Biotech Uni-Gold
Unsure - not currently testing
Other rapid test (answer next question)

Reporting
Is your laboratory reporting all AIDS-related test results to the WV Bureau for Public Health Surveillance and Disease Control program?*

YesNo
All AIDS-related test results must be reported to the WV Office of Epidemiology and Prevention Services (OEPS) per the WV Reportable Disease Rule. Please visit the OEPS website for more information.

Payment
How will your laboratory pay the certification fee?*

Online via credit cardCheck via mail
The link to the online payment system will be displayed on the submission confirmation page; it will also be included in your submission email if you need to return at a later time.
An invoice will be sent in a separate email. Please return this form with your check.

In order to prevent processing delays, please be sure to include your CLIA number on the check!

EFFECTIVE 1/1/2024, CHECKS MUST BE MADE PAYABLE TO "DEPARTMENT OF HEALTH"

Review and Submit
Please type your name below to attest that the information provided within this survey is true and accurate to the best of your knowledge. *
Reminder: all follow-up emails and documents will be sent from noreply@jotform.com.

Please add this address to your contacts or safe senders list to ensure you receive further communications.
Click "Review Answers" to verify your information is correct and submit the form.
Should be Empty:

WV AIDS-Related Testing Facilities: Waived

Laboratory and CLIA Information

Contact Information

Multiple Site Exceptions

Testing Information

Personnel, Procedures, and Testing Materials

Reporting

Reference Laboratory

Payment

Review and Submit