West Virginia CLIA Program: Electronic Notifications

West Virginia CLIA Program

Electronic Notifications
CLIA ID*
Facility Name*
Email Address for CMS Communications*
example@example.com
Do you want to submit an enrollment or change request for additional labs?*

YesNo
Enter the additional labs in the following table. Use the "Add Lab" button to add a new row.

Please do not add the facility you previously listed on this form to the table.

You may provide a different email address for each facility, but at this time the CLIA system can only accommodate one address per laboratory record. If you enter the same facility with different email addresses in this table, we will choose one on your behalf.
Additional Laboratories
By selecting "Yes," I acknowledge that I am enrolling in electronic notifications and will no longer receive paper documents via mail.*

Yes
By selecting "Yes," I verify that I have the authority to make this request on behalf of the facility.*

Yes
By selecting "Yes," I understand that any changes to the email address on file must be communicated immediately to ensure delivery of fee invoices and CLIA certificates.*

Yes
Emails will be sent from noreply-cms-ccsq@ccsq.cms.hhs.gov. Please add this address to your contacts or safe senders list to ensure delivery. If you work for a large organization, we recommend reaching out to your IT department to ensure the messages are not filtered out completely by your firewall.
Contact Name*

First NameLast Name
Contact Email*
example@example.com
Relationship to Facility*
Signature*

Powered by Jotform SignClear
Should be Empty: