Wisconsin COVID-19 Test Plan Request

This website is for healthcare providers only. If you are an individual experiencing COVID-19 symptoms, please visit wihealthconnect.com for more information and COVID-19 screening.

Wisconsin COVID-19 Test Plan Request

You have indicated that you are a Skilled Nursing Facility

If you are not a Skilled Nursing Facility please use the request form here.

Please enter one request per facility. Multiple facilities may not be accommodated with one request.

Enter your organization name.

Organization

You can also search by NPI.

Requester Contact Information

Enter your contact information, including your direct line phone number, to avoid delays should we need to contact you regarding details for your order.

Prefix

First Name

Last Name

Phone Number

Company or Organization

Address

Address 2

City

County

State

Zip Code

Shipping Information

Be sure to fill an appropriate shipping address (no PO Box address). Provide the name and phone number for the staff member responsible for receiving the shipment.

Prefix

First Name

Last Name

Company or Organization

Attention

Shipping Attention Phone Number

Address

Address 2

City

County

State

Zip Code

Notes

Notes or Comments (500 character max)

Provide details on the following: the name of the lab you are working with, the status of your outbreak (residents or staff?)

Terms of Acceptance of Specimen Collection Supplies and Laboratory Services

As a condition of receiving COVID-19 testing specimen collection supplies and/or laboratory services at no cost from the State of Wisconsin, you agree to:

Use and administer the specimen collection supplies and laboratory services only in compliance with all applicable laws, regulations, rules, authorizations, and guidance ("Applicable Law");
Have specimens collected by qualified personnel using proper procedures;
Ensure that personnel collecting specimens are trained in proper collection procedures;
Order laboratory services for such specimen in compliance with all Applicable Law;
Have laboratory services ordered only by authorized health care professionals;
Communicate results of COVID-19 tests in compliance with all Applicable Law; and
Obtain all necessary consents and authorizations from patients to perform laboratory services and release the results of those services to the Wisconsin Department of Health Services (DHS) or its designees.
Order only the supplies and/or related laboratory services necessary to meet your needs over the next 7-14 days.
Account for unused supplies and report to the State upon its request. Unused supplies must be allocated to a future test plan within 14 days; the State reserves the right to have unused supplies returned to the State.

You also agree not to:

Bill third parties for the specimen collection supplies and laboratory services; or
Use the specimen collection supplies and laboratory services to provide COVID-19 testing services to State of Wisconsin government entities, including but not limited to universities in the University of Wisconsin System, unless otherwise agreed to in writing by the DHS or the Wisconsin Department of Administration.

I Accept The Terms Outlined Above