Wisconsin COVID-19 Test Plan Request

This website is for qualified Wisconsin organizations 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 your facility is an Assisted Living Facility

Enter your organization name. TIP: Enter fewer letters for more results.

Organization

If you do not find your Facility in the results below, return to the previous page and select Other Organization to place your order.

Search by Address.

Address Search

Enter your address information. Both fields are required.

Street Address

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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.

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First Name

Last Name

Phone Number

Company or Organization

Address

Address 2

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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

Antigen Testing Supplies

Qualifying Wisconsin health and safety entities can request antigen kits to provide onsite rapid testing.

If applicable, provide approximate amount of individual antigen tests in stock at your location.

Number of Antigen Tests Needed.

Provide CLIA Number for your Facility.

If you do not have a CLIA Number, please contact DHSDQACLIA@dhs.wisconsin.gov to apply for one.

Please provide a brief description of how the tests will be used.

Does your facility currently have access to PCR Testing services? (In-house, Contracted Lab, Community Testing, etc)

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;
For PCR testing, order laboratory services for such specimen in compliance with all Applicable Law;
For PCR testing, 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 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. 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