State of California—Health and Human Services Agency |
California Department of Public Health |
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Radiologic Health Branch |
Radiologic Technologist Fluoroscopy Permit Application
(Failure to use your full legal name may result in entrance into the examination being denied.)
Last Name (Please Print) |
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Date of Birth |
Social Security Number |
Phone Number |
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Mailing Address |
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E-mail Address |
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ATTENTION! You must provide one of the following requirements for your application to be considered:
Current California Diagnostic Radiologic Technology Certificate Number: Or
A completed application for a Diagnostic Radiologic Technology Certificate with your American Registry of Radiologic Technologists (ARRT) Certificate in Radiography.
Pursuant to the authority found in Section 114870 of the California Health and Safety Code and as required by Section 17520 of the California Family Code, providing the social security number is mandatory. The social security number will be used for purposes of identification. The information on this form may be provided to federal, state, or local agencies for law enforcement purposes. This information may also be provided to the American Registry of Radiologic Technologists for examination purposes. For information or access to your records, contact the Registration and Certification Support Unit at the California Department of Public Health, Radiologic Health Branch (CDPH-RHB), MS 7610, P.O. Box 997414, Sacramento, CA 95899-7414, (916) 327-5106.
HOW DO I OBTAIN A CALIFORNIA RADIOLOGIC TECHNOLOGIST FLUOROSCOPY PERMIT?
You must submit this application along with the following:
•The non-refundable application fee of $88.00 in the form of a check (e.g., personal, cashier’s, or certified check) or money order made payable to CDPH-RHB, and one of the following:
A copy of your graduation diploma or certificate from a CDPH-RHB approved radiologic technologist fluoroscopy school; or
Documentation that you graduated from a diagnostic radiologic technology program accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT) and passed the American Registry of Radiologic Technologists (ARRT) radiography examination; or
Documentation that you are certified by ARRT in radiography and a current ARRT registrant.
HOW WILL I BE NOTIFIED ABOUT THE STATUS OF MY APPLICATION?
Within 30 calendar days of receipt of your application, CDPH-RHB will mail you a notification letter. The notification letter will inform you of one of the following:
•That your application is acceptable and what examination you must pass within one calendar year in order to obtain the certificate/permit, and instructions on how to submit payment of the non-refundable examination fee; or
•That your application is not accepted for filing and what specific information, documentation or fee you must submit within 30 calendar days in order for CDPH-RHB to consider the application acceptable.
CDPH 8218 (1/15) |
Page 1 of 2 |
State of California—Health and Human Services Agency |
California Department of Public Health |
|
Radiologic Health Branch |
Radiologic Technologist Fluoroscopy Permit Application
(Failure to use your full legal name may result in entrance into the examination being denied.)
HOW DO I SUBMIT MY APPLICATION?
Please mail this application, all supporting documents, and payment for the non-refundable application fee of $88.00 to:
California Department of Public Health
Radiologic Health Branch, MS 7610 Accounts Receivable and Cashiering Unit P.O. Box 997414
Sacramento, CA 95899-7414
I certify that the information provided with this application is true and correct. I understand that the California Department of Public Health may revoke certificates or permits that are procured by fraud, misrepresentation, or mistake, or for the nonpayment of fees. Further, I am aware that it is unlawful to use X-rays on human beings in this state unless I have been granted a certificate or permit pursuant to the Radiologic Technology Act, am acting within the scope of that certificate or permit, and am acting under the supervision of a licentiate of the healing arts who is a certified supervisor or operator.
CDPH 8218 (1/15) |
Page 2 of 2 |
