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Medical Test Site (MTS) Application - Certificate of Waiver - doh wa 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Section #1: Demographic Information. Enter your Uniform Business Identifier Number (UBI #) and Federal ID Number (FEIN#). Fill in the Legal Owner/Operator Name, Mailing Address, Phone and Fax Numbers, Email, and Web Address.
- Proceed to Section #2: Facility Specific Information. Select the applicable site type and provide the Facility Specific Federal Tax ID if different from the Owner FEIN.
- In Section #3: Key Individuals, enter details for the Lab Director and Lab Contact Person including their names, professional license numbers, and email addresses.
- For Section #4: Additional Information – Waived Tests, check all tests performed at your facility. If you perform any tests beyond those listed, do not complete this application.
- Finally, complete Section #5 by listing legal owner information and signing the form. Ensure all details are accurate before submission.
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What type of certificate for laboratories doing waived testing?
Certificate of Waiver (COW): Issued to a laboratory that performs only waived tests. in which a physician, midlevel practitioner or dentist performs specific microscopy procedures during the course of a patients visit.
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Page 3. o Have a Certificate of Waiver MTS/CLIA license (if applicable based on test type above). License number: 50D22077622 o Report all test results, both
Certificate of Waiver Application. Please contact Facilities Customer Service at 360-236-4985 if you have any questions or need assistance in completing the