Special Renewal Application Form PDF Details

The Special Renewal Application form, provided by the State of California—Health and Human Services Agency through the California Department of Public Health Radiologic Health Branch, represents a crucial document for X-Ray Technician Bone Densitometry Limited Permit holders eyeing to renew their credentials. Specifically designed for individuals who did not receive their renewal billing notice 45 days ahead of their permit's expiration date post-January 31, 2015, due to a fee hike, the form outlines a streamlined process to maintain professional licensing without interruption. The application encapsulates vital information including personal identification, permit number, and fee structure, dependent on the timeliness of the renewal submission and ranging from $82.00 for current permits to $176.80 for permits expired within the past 5½ years. Highlighting the significance of ongoing education, the application mandates the completion of 24 approved continuing education credits over the previous two years, a move aimed at ensuring that technicians remain updated with the latest radiologic practices and technologies. Moreover, the form allows for address updates and includes a section for those wishing to cancel their permit, with a stern reminder of the implications such a request harbors regarding reinstatement. Mirroring the state’s commitment to professional integrity and patient safety, the renewal procedure emphasizes accuracy and honesty in reporting, alongside a declaration that all provided information is true, under penalty of perjury. This comprehensive approach not only facilitates the renewal process but also reinforces the high standards expected of practitioners within California’s healthcare landscape.

QuestionAnswer
Form NameSpecial Renewal Application Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrhb ca, rhb renewal online form, radiologic health branch renewal application, california fluoroscopy license renewal online

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State of California—Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

Please Use this Renewal Application if your permit expires on or after January 31, 2015 due to fee increase

SPECIAL RENEWAL APPLICATION*

* This application is for use only by those who did not receive their renewal billing notice 45 days before their expiration date.

For X-Ray Technician Bone DensitometryLimited Permit

Permit Number

 

 

Permit ExpirationDate

 

 

 

 

 

Last Name, suffix

 

First Name

 

Middle Name

 

 

 

 

Mailing Address

Check this box if your address has changed since your last permit was issued.

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

PhoneNumber

 

 

 

 

 

It is very important that you provide your full true name. Pursuant to the California Code of Civil Procedure Section 1275, name change requests must be accompanied by a copy of a certified superior court order allowing the name change and a government issued picture ID, such as a driver’s license, military ID, or passport.

Return this completed application with your applicable nonrefundable renewal fee payment in the form of a check or money order payable to “CDPH-RHB”:

$82.00 if your permit has not expired.

$94.80 if your permit expired within the past six months. $176.80 if your permit expired within the past 5½ years.

Note: Permits cannot be renewed after 5½ years from the expiration date. You will need to reapply.

A valid temporary authorization will be available to view and print for work purposes, within 24-48 hours after your renewal is processed, at http:/ / rhbxray.cdph.ca.gov/ .

You are required to earn 24 approved continuing education credits within the past two years. Complete extra copies of page 2 of this application if needed to list the required approved continuing education credits you have earned and return them along with this page and payment to:

Billing and Cashiering Unit

Overnight/express mail (USPS, FedEx, etc.) must be sent to:

California Department of Public Health

Billing and Cashiering Unit

Radiologic Health Branch

CDPH-RHB

MS 7610

1500 Capitol Avenue, Suite 520,

P.O. Box 997414

MS 7610, Bldg. 172

Sacramento, CA 95899-7414

Sacramento, CA 95814-5006

REQUEST FOR CANCELLATION Please note: If you request to cancel your permit, you are not eligible for reinstatement and will need to reapply for a new permit.

I wish to cancel my permit.

CDPH 8232 BD SRA II (10/16)

Page 1 of 2

State of California—Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

Earned Approved Continuing Education Credits for Renewing a California X-Ray Technician Bone Densitometry Limited Permit

To renew a California X-Ray Technician permit, you are required to return this completed application along with your renewal fee. Do not submit copies of your certificates. You are required to maintain proof of continuing education for four years, to be provided upon request.

Permit Number

Permit ExpirationDate

Last Name, suffix

First Name

An approved continuing education credit is one hour of instruction received in subjects related to the application of X-ray to the human body and accepted for purposes of credentialing, assigning professional status, or certification, by any of the following groups*:

(a)American Registryof Radiologic Technologists (ARRT), (b) Medical Board of California, (c) Osteopathic Medical Board of California,

(d)Board of Podiatric Medicine, (e) California Board of Chiropractic Examiners, (f) Board of Dental Examiners.**

I have earned the following 24 approved continuing education hours/credits.

Additional Requirements (Check applicable box)

I attest that four of the credits provided are in digital radiography.

CourseTitle

Provider or Sponsor

Location (City, State)

Date

Code**

Hours*

 

 

 

 

 

CourseTitle

 

 

 

 

 

 

 

 

 

Provider or Sponsor

Location (City, State)

Date

Code

Hours

 

 

 

 

 

CourseTitle

 

 

 

 

 

 

 

 

 

Provider or Sponsor

Location (City, State)

Date

Code

Hours

 

 

 

 

 

CourseTitle

 

 

 

 

Provider or Sponsor

Location (City, State)

Date

Code Hours

CourseTitle

Provider or Sponsor

Location (City, State)

Date

Code Hours

I certify that the information provided in this application for renewal 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 am certified pursuant to the Radiologic Technology Act, I am acting within the scope of that certification, and I am acting under the supervision of a licentiate of the healing arts who is a certified supervisor or operator.

Signature

Date

CDPH 8232 BD SRA II (10/16)

Page 2 of 2

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The way to prepare california fluoroscopy license renewal online portion 1

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3. This next step focuses on Permit Number, Permit Expiration Date, Last Name suffix, First Name, An approved continuing education, I have earned the following, I attest that four of the credits, Course Title, Provider or Sponsor, Location City State, Date, Code Hours, Course Title, Provider or Sponsor, and Location City State - complete all these fields.

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