West Virginia CLIA Program: Electronic Notifications

West Virginia CLIA Program

Electronic Notifications
Do you need to change any of your laboratory's information, such as the laboratory director, facility name, or physical address?
This form may ONLY be used to enroll in electronic notifications or update the email address on file.

Please submit a single request to enroll/change the email address and update the other data fields. Guidance for change requests can be obtained here.

If you cannot open this link, submit a request for a PDF version using the guidance request form. The document will be emailed to you immediately upon submission.

West Virginia CLIA Program

Electronic Notifications
CLIA ID
Facility Name
Name of Laboratory Director or Owner
Email Address for CMS Communications
example@example.com
Do you want to submit an enrollment or change request for additional labs?
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")
By selecting "Yes," I acknowledge that I am enrolling in electronic notifications and will no longer receive paper documents via mail.
By selecting "Yes," I verify that I have the authority to make this request on behalf of the facility.
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.
By selecting "Yes," I acknowledge that this form is only used to add or update an email address, not change the laboratory's name or director.
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
Should be Empty: