West Virginia CLIA Program: Electronic Notifications

West Virginia CLIA Program

Electronic Notifications
CLIA ID*
Facility Name*
Name of Laboratory Director or Owner*
Email Address for CMS Communications*
example@example.com
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.
Additional Laboratories (if the email address and director/owner are the same as those of the first facility, you can type "same")
Yes
Yes
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*

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