CLIA Waiver Program

Organization Legal Name:*

Address:*

(Street, City, State, Zip)

Name of Contact Person:*

Contact Phone:*

Phone

Contact Email:*

Category

Primary CLIA plus optional OTC

Own CLIA plus optional OTC

OTC Only

Not Currently Testing

Do you need support purchasing or sourcing test kits?

Yes

No

Are you interested in collaborating with Primary to develop an insurance reimbursement path for your program?

Yes

No

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