Certificate of Waiver Medical Test Site 2026

1. Click ‘Get Form’ to open the Certificate of Waiver Medical Test Site application in the editor.
2. Begin with Section 1: Demographic Information. Fill in your Uniform Business Identifier (UBI) number and Federal ID number if applicable. Ensure that all entries are clear and accurate.
3. Continue to provide the Legal Owner/Operator Entity Name, complete mailing address, and contact details including phone, fax, email, and web address.
4. In Section 2: Facility Specific Information, select the appropriate site type from the provided options. If you have additional locations under this license, attach a list as instructed.
5. For Section 3: Key Individuals, enter the names and professional license numbers of both the Lab Director and Lab Contact Person along with their email addresses.
6. In Section 4: Additional Information—Waived Tests, check all applicable tests performed at your facility. Verify their waived status on the FDA website as needed.
7. Complete Section 5 by listing any other licensure or certification information required. Ensure to sign and date at the end of the form before submission.

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