Get Ca Cdph 8679 2020-2025

This guide provides step-by-step instructions for filling out the CA CDPH 8679, the home medical device retailer license application. Completing the form accurately is crucial for ensuring that your application is processed smoothly.

Follow the steps to complete the CA CDPH 8679 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the license number section. If this is a new application, leave this blank. If applicable, enter the previous license number.
3. Indicate whether you are a new applicant, renewal applicant, or making a change in ownership or location by checking the appropriate box.
4. Provide the legal name of your firm in the 'Name of Firm' field.
5. If your firm operates under a different name, fill in the 'DBA' field.
6. Enter the facility address including number, street, city, state, and zip code in the facility address section.
7. Fill out the mailing address if it is different from the facility address.
8. If the facility is outside the United States, specify the country in which it is located.
9. Include your website URL if applicable.
10. Select the type of ownership from the options provided and attach evidence of ownership.
11. Enter the owner's name or corporate name along with the state of incorporation if applicable.
12. List the names and titles of the owners or officers responsible for the application.
13. Select the type of application you are submitting by marking the appropriate box.
14. Indicate the type of business you will conduct at this location and record the business days and hours.
15. Check all applicable products your business will be selling.
16. Answer the questions regarding selling or renting prescription devices and provide necessary documentation if applicable.
17. Respond to questions regarding Medi-Cal or MediCare provider numbers, and attach proof if applicable.
18. Fill in the payment code section indicating the fees applicable to your application.
19. Sign the application where indicated, providing your printed name, title, and the date.
20. Provide business operator and correspondent information including names, contact numbers, and email addresses.
21. After completing the form, save changes, download, print, or share the form as necessary.

Start filling out the CA CDPH 8679 online today to ensure compliance and proper licensing.