West Virginia CLIA Program: Electronic Notifications Screener

West Virginia CLIA Program: Electronic Notifications
Is your laboratory physically located in West Virginia?*

YesNo
This form is ONLY to be used by facilities in West Virginia. Please contact your state's CLIA agency. Contact information can be found at https://www.cms.gov/medicare/quality/clinical-laboratory-improvement-amendments/contacts.
What change are you requesting?*

Enroll in electronic notifications or update the email address on file with CLIASomething else
This form is ONLY for enrolling in electronic notifications or changing your email address. Please contact dholsclia@wv.gov if other changes need to be made.
Have you already contacted us (via email, letter, or 116 application) to add or update your electronic notifications?*

YesNo
You do not need to do anything further. We will process your request and notify you once complete. Submitting multiple requests will delay processing and a response.
Click the link below to access the electronic notifications change form.

https://form.jotform.com/251246249785062
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