Please also include a copy of your ARC/IATA/TRUE/CLIA certificate.Īfter saving your documents (W-9, Accreditation certificate), print, and submit completed forms with owner's signature by fax to 40, by email to or by mail to Vacation Express, Attn: Accounting, 3500 Piedmont Rd., Ste. A Dual 510 (k) and CLIA Waiver by Application (Dual Submission) is a single submission containing a complete 510 (k) and CLIA Waiver by Application package. Section 6676 of the Code currently provides for mandatory backup withholding of 31% for failure to give an identification number to a payer (W-9 pdf). In addition to the Federal CLIA requirements, many states separately license, register, or certify diagnostic laboratories. IRS Code Section 6019, recipient payments are required to provide federal tax identification numbers to payers. Consequently, a CLIA-certified facility that performs a COVID-19 self-test for a patient or interprets the results of such a test must report the test results in accordance with Federal and state requirements. To comply with Internal Revenue Service requirements for Form W-9 information, we are requesting your federal tax identification number. By submitting your information you are also consenting to receiving information from Vacation Express regarding new promotions and travel offers.
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