In the State of California, professionals in the nuclear medicine technology sector are required to maintain their certifications through the California Department of Public Health's Radiologic Health Branch. The CDPH 8435 SRA form serves a critical role in this process, particularly for those who find themselves in a somewhat precarious position – not having received their renewal billing notice at least 45 days before their certificate's expiration date. This specialized renewal application aims to bridge that gap, ensuring that these professionals can continue to practice without interruption due to administrative oversights. The form requests crucial details such as the certificate number, the expiration date, and personal identification to ensure accuracy in processing. It also outlines the necessary fees for renewal, which vary depending on the certificate's status at the time of renewal. Additionally, it mandates the inclusion of documentation confirming the applicant's participation in continuing education, a requirement that underscores the state's commitment to maintaining high standards in the healthcare field. The process is rounded off with a declaration of the truthfulness of the information provided, a safeguard against fraudulent claims, and a reminder of the legal frameworks that govern the use of radiologic technology in California. This form, therefore, not only facilitates the administrative aspect of certification renewal but also reinforces the legal and educational standards essential for safe and effective healthcare delivery.
| Question | Answer |
|---|---|
| Form Name | Form Cdph 8435 Sra |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | rhb, nonrefundable, cdph8435sra3, Radiologic |
State of |
California Department of Public Health |
|
Radiologic Health Branch |
Please Do Not use this Renewal Application if your certificate expires on or after
January 31, 2015 due to fee increase
*SPECIAL RENEWAL APPLICATION
* This form is for use only by those who did not receive their renewal billing notice 45 days before their expiration date.
California Nuclear Medicine Technology Certificate
Number of Scopes Issued |
Certificate Number |
Certificate Expiration Date |
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|
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Last Name, suffix |
First Name |
Middle Name |
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Mailing Address Check this box if this is a change of address since your last certificate/permit was issued.
City
State
ZIP Code
Phone Number
It is very important that you provide your full true name.
Return this form along with your applicable nonrefundable renewal fee payment in the form of a check
or money order made payable to
$175.00 if your certificate has not expired.
$218.75 if your certificate has expired.
Attach documentation that establishes your participation in management sponsored or formal continuing education offered by professional organizations or societies or institutions of higher learning. This education and training is required to be of at least five clock hours in each of the scopes for which your certificate was issued since your last certificate renewal or initial application.
Include your nonrefundable fee payment with attachments and mail this form to:
Billing and Cashiering Unit
California Department of Public Health
Radiologic Health Branch
MS 7610
P.O. Box 997414
Sacramento, CA
I certify that all information provided with this application is true and correct. I understand that the California Department of Public Health may cancel certificates that are procured by fraud, misrepresentation, or mistake, and may revoke certificates for the nonpayment of fees. Further, I am aware that it is unlawful to use
Signature
Date
CDPH 8435 SRA (10/14) |
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