The CDPH 8391 form is used to report name or address changes for radiologic professionals in California. It is required under the California Code of Regulations, Title 17, sections 30406 and 30537. The California Department of Public Health Radiologic Health Branch administers this requirement and maintains records for all licensed practitioners in the state.
This form applies to all major radiologic credentials issued by California. These include the X-ray Technician Limited Permit and the Radiologic Technology Certificate. The Mammographic Radiologic Technologist Certificate and Fluoroscopic Certificate are also covered. Supervisor and Operator Certificate or Permit holders must file as well. Nuclear Medicine Technologist Certificate holders are required to submit this form too.
All credential holders must report any change within 30 days of the change date. For a name change, a certified court order must be attached to the form. A copy of a government-issued photo ID is also required. These documents confirm the legal name change and verify identity for the department.
The form also serves as an application for individuals taking California state radiologic technology examinations. It supports early career entry into the radiologic field. Submit the completed CDPH 8391 form by mail or fax to the CDPH Radiologic Health Branch in Sacramento. Email submissions are not accepted by the department.
| Question | Answer |
|---|---|
| Form Name | Cdph 8391 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Pursuant, Fluoroscopic, cdph8391, Technologist |