Order Form - Professional CLIA-Waived COVID-19 Antigen Tests (Legacy)

This order form is for organizations who are already approved, onboarded, and actively testing with the State of California’s CLIA-waived testing program.

This order form is for Professional CLIA-waived COVID-19 antigen tests, NOT At-Home (OTC) COVID-19 tests.

To order At-Home COVID-19 tests instead, click HERE.

Planning for Tests

Tests must be stored indoors and temperature-controlled (35.6-86°F)
Email confirmation is sent when an order is submitted and when it is approved.
Please allow 1-3 weeks for delivery.

Are you a state-level government agency or department (e.g., California Department of Transportation, California Natural Resources Agency, etc.) that is testing staff as part of the State Employee Testing Program?

Attestations

By placing this order, you agree to the following:

Your organization CANNOT charge people for COVID-19 tests provided by the CDPH.

Your organization CANNOT bill patients' insurance for COVID-19 tests provided by the CDPH.

Only people who have completed all CDPH training requirements for BinaxNOW COVID-19 testing may use tests or report results.

Sites that allow uncertified people to access or report the tests will be suspended from testing.

Reporting all BinaxNOW COVID-19 test results in Primary.Health is required.

Organization Information

Is this a child care, camp, school, foster program or other organization that primarily serves people under age 18?

Which of these best describe your organization type?

Organization Name

Please do not abbreviate or use acronyms.

Organization Point of Contact (Person Placing Order)

First Name

Last Name

Email Address

Phone Number

Verify Email Address

Delivery Point of Contact (Person Receiving the Shipment)

Provide direct phone number (cell phone is best) to coordinate delivery of testing materials
Be available at shipping address to receive during working hours

Delivery POC Same as Org POC

Delivery POC First Name

Delivery POC Last Name

Delivery POC Email

Delivery POC Phone

Must be the person’s direct number (cell phone is best; no extensions).

Secondary Delivery Contact Name

Secondary Delivery Contact Phone

Must be the person’s direct number (cell phone is best; no extensions).

Delivery Information

Important: Please review and verify your address to avoid delays.

No P.O. Boxes; must be a street address
Must be in California
Delivery Point of Contact must be at the address to receive the shipment

Please consolidate orders. When possible, ship to a central location like a headquarters or district office. If tests must be shipped to more than one location, submit a separate order for each address.

Attention

Street Address

Building/Suite

City

County

Zip Code

Additional Delivery Instructions

Receiving Hours

Test Information

Approximate BinaxNOW Antigen Tests Remaining from Prior Orders

Total BinaxNOW CLIA-Waived Antigen Tests Requested (please order a 12-week supply for testing at all locations for your organization)

[Multiples of 640 Tests] 1 case of 640 tests contains 16 boxes (each with 1 control swab and 40 tests).

Additional Comments, Explanations, or Requests:

Additional Comments

If you are ordering more than 1,920 antigen tests (3 cases) or need additional control swabs (for training more than 18 people), please explain below.

Please verify your order for accuracy before you submit.

Your order information will be reviewed by our staff. You will receive an email when your order is confirmed, usually within 1 week. Delivery may take up to 3 additional weeks.

For additional questions, please email communityrapidtesting@cdph.ca.gov