Get Ca Cdph 8623 2007-2025

The CA CDPH 8623 is a crucial form for the certification of mammography facilities and machines in California. This guide provides clear and supportive instructions on how to complete the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to successfully complete the CA CDPH 8623 online.

1. Click the ‘Get Form’ button to access the form and open it in the appropriate editor.
2. Begin with Section 1, titled 'Facility status'. Check the appropriate category box for your application, such as 'New facility' or 'Renewal', and circle the relevant selections.
3. Continue to fill in the 'Current FDA facility identification number' and 'FDA certificate expiration date' as well as the 'State registration number' and its expiration date.
4. In Section 2, 'Facility address information', provide the facility name, doing business as (DBA) name if applicable, and contact person's details, including their title and phone number.
5. Complete the 'Employer Identification number' and fill in the facility's location and mailing addresses, ensuring to include city, state, and ZIP code.
6. Move to Section 3 to address the 'Facility mammography accreditation history'. Indicate whether there has been a previous application for certification at the location and whether any accreditation status has ever been denied.
7. Section 4 requires details about the 'Facility procedure information', including whether you accept self-referrals and the number of screening and diagnostic procedures performed annually.
8. In Section 5, answer questions about participation in the 'Every Woman Counts Program' and provide the necessary Medi-Cal number.
9. Section 6 involves listing qualifications for personnel including physicians and technologists. Ensure to check each individual's qualifications and provide specific information as required.
10. Fill out Section 7 with details about the mammography equipment, including make, model, and control serial numbers for each machine present at your facility.
11. Attach the latest physicist reports in Section 8, ensuring they are not older than 12 months and include corrective actions taken for any deficiencies noted.
12. Finally, complete Section 9, 'Acknowledgment and certification', by providing the required signatures, dates, and printed names of both the facility owner or administrator and the lead interpreting physician.
13. After ensuring all sections are accurately filled out, save the changes, and choose to download, print, or share the form as required.

Complete your CA CDPH 8623 online today to ensure your mammography facility remains compliant and certified.