Get Blank Odh Self Referral Application

Filling out the Blank Odh Self Referral Application online is a crucial step for registration of radiation-generating equipment. This guide provides clear and detailed instructions to help users effectively complete the application.

Follow the steps to successfully complete the application process.

1. Press the ‘Get Form’ button to access the application and open it in your preferred online editor.
2. Enter the registrant or facility name, ensuring it matches the official name on your IRS 147C letter. This is essential for accurate identification.
3. Select the applicant category from the provided options. Only one category should be chosen. Options include Chiropractic Office, Dental Office, Physicians Office, and several others.
4. Input your federal tax ID number as it appears on the 147C letter. If you do not have a federal tax ID number, contact the Bureau for guidance.
5. Provide the individual responsible for radiation protection. Include their name, email address, and contact information.
6. Fill in the mailing address. If applicable, select the option to use the same address for billing and x-ray source locations. Ensure all addresses are complete and accurate.
7. List the total number of x-ray tubes you handle at the location. This section requires both operable and inoperable quantities to be noted.
8. Complete any additional information as applicable. Ensure you adhere to the required timelines outlined in the introductory sections.
9. Review all entries for accuracy and completeness. Make any necessary adjustments before finalizing your submission.
10. Once finished, you can save your changes, download the completed application, print it for your records, or share it as needed.

Complete your application online today for efficient and timely processing.