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. 

Per CMS, effective 10/17/2025, your facility must contact its accreditation organization (AO) to enroll in electronic notifications and to verify or update the email address on file. 

If the AO will not process the request, please email our office at dholsclia@wv.gov. 

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.

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