Get Request For Name/address Change And/or Duplicate ... - Cdph Home

This guide provides comprehensive instructions for completing the Request For Name/Address Change And/or Duplicate form from the California Department of Public Health. Follow these steps to ensure your request is completed accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access and open the Request For Name/Address Change And/or Duplicate form in your preferred online editor.
2. Carefully fill out Part I of the form with your personal details. This includes your first name, last name, date of birth, social security number, telephone number, and your mailing address (including city, state, and zip code). Make sure to type or print clearly.
3. Indicate any previous names under which you were certified, and provide your original certificate number along with the original date of certification.
4. In this section, provide details regarding your certification status. Specify if you have documentation related to any past incidences involving abuse, neglect, or misappropriation of property. Attach any necessary explanations.
5. Input any felony convictions you may have and attach the appropriate documentation, if applicable.
6. Confirm your disciplinary status by providing information on whether you are currently listed on the Nurse Aide Registry and if you have met all federal requirements.
7. Complete the method of certification section by checking all that apply and providing the relevant dates for your competency evaluation.
8. Once all sections are completed, review the form for accuracy before finalizing. You can then save your changes, download, print, or share the completed form as needed.

Complete your form online today to ensure a smooth and timely processing of your request.