Get Application For Mammography Facility/machine Certification. Cdph 8623 - Cdph Ca

The Application For Mammography Facility/Machine Certification, CDPH 8623, is essential for facilities seeking certification to perform mammography services in California. This guide provides comprehensive instructions to help you successfully complete the application online.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to access the application form and open it in the editor.
2. In Section 1, select the appropriate facility status by checking one of the category boxes. Circle the relevant options for new facilities, machines, renewals, and changes. Ensure you include a Radiation Machine Registration Form RH 2261 for certain actions.
3. Provide the current FDA facility identification number and expiration date in Section 1b, followed by the state registration number and its expiration date.
4. In Section 2, fill out the facility address information including the facility name, contact information, and employer identification number.
5. In Section 3, indicate whether you have applied for FDA MQSA certification for the physical location. If applicable, address any previous denials or issues with accreditation.
6. Section 4 requires you to provide the number of screening and diagnostic procedures performed at your facility each year.
7. Complete Section 5 by indicating participation in the Every Woman Counts Program and providing the nine-digit Medi-Cal number.
8. In Section 6, list physician and technologist qualifications, including their certifications and state registration numbers.
9. Document the mammography equipment in Section 7 by providing details of each machine and film processor used at your facility.
10. Attach the most recent physicist's report in Section 8 and any corrective actions taken based on that report.
11. Finally, in Section 9, read the acknowledgment and certification statement carefully, sign and date it, and ensure that all parts of the application are complete before submission.

Complete your application online today to ensure your facility is certified for mammography services.