CA CDPH 8623 2017-2025 free printable template
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State of California Health and Human Services Agency California Department of Public Health Radiologic Health Branch Application for Mammography Facility/Machine Certification Section 1 Facility Status a. Type of Facility check one Biopsy-Only Facility ACR/MQSA Facility Other specify b. Reason for Submittal check all that apply New Facility Renewal Ownership Change Name Change Address Change Personnel Change Submit with a radiation machine registration form RH 2261. c* State Registration...
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How to fill out CA CDPH 8623
01
Obtain the CA CDPH 8623 form from the California Department of Public Health's website.
02
Fill out the top section with your personal information, including your name, address, and contact details.
03
Provide details about the entity or facility relevant to your application, including its name and address.
04
Complete the section that requires information about the program or service being provided.
05
Include any required documentation or supporting materials as specified in the instructions.
06
Review the form to ensure all information is accurate and complete.
07
Sign and date the form where indicated.
08
Submit the form to the appropriate department by mail or electronically, following the submission guidelines.
Who needs CA CDPH 8623?
01
Individuals or organizations that are applying for a California Department of Public Health permit or license related to specific healthcare services.
02
Facility operators or managers who need to demonstrate compliance with state health regulations.
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What is CA CDPH 8623?
CA CDPH 8623 is a reporting form used by healthcare facilities in California to report cases of certain diseases and conditions to the California Department of Public Health.
Who is required to file CA CDPH 8623?
Healthcare providers, including physicians and other licensed practitioners, as well as healthcare facilities such as hospitals and clinics, are required to file CA CDPH 8623 when they identify reportable conditions.
How to fill out CA CDPH 8623?
To fill out CA CDPH 8623, you need to complete the required fields with patient information, disease details, and the reporting healthcare provider's information as specified in the instructions provided by the California Department of Public Health.
What is the purpose of CA CDPH 8623?
The purpose of CA CDPH 8623 is to monitor and control the spread of communicable diseases in California by ensuring timely and accurate reporting of disease cases to public health authorities.
What information must be reported on CA CDPH 8623?
The information that must be reported on CA CDPH 8623 includes patient demographics (name, date of birth, sex), diagnosis, date of onset, healthcare provider information, and any other relevant clinical information related to the disease.
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