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Get Ca Cdph 8623 2017-2025
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How to fill out the CA CDPH 8623 online
The CA CDPH 8623 is the application form for mammography facility and machine certification in California. This guide provides a clear and supportive step-by-step approach for users to successfully complete the form online.
Follow the steps to fill out the CA CDPH 8623 online effectively.
- Press the ‘Get Form’ button to access the CA CDPH 8623 form and open it in your preferred editing tool.
- Begin with Section 1 where you need to specify the facility status. Select the type of facility by checking the corresponding box such as 'Biopsy-Only Facility', 'ACR/MQSA Facility', or 'Other'. Also, indicate the reason for submission by checking all applicable options.
- In Section 2, provide comprehensive facility information. Include details such as the facility name, contact name, phone number, email address, and both the location and mailing addresses.
- Proceed to Section 3 to fill out the facility's mammography accreditation history. Indicate whether you have previously applied for FDA MQSA certification and if your facility’s accreditation status has been denied or revoked.
- In Section 4, detail the facility procedure information, specifically the number of various mammography procedures performed.
- Fill out Section 5 by providing any associated program information, including participation in the Every Woman Counts Program.
- Section 6 requires personnel qualifications. List all physicians, technologists, and physicists, ensuring to include their qualifications and certification details.
- For Section 7, provide information about the mammography equipment used, including the machine listing and specifications.
- Attach the medical physicist report required in Section 8, ensuring it meets the necessary evaluation criteria.
- Complete Section 9 by acknowledging and certifying the information provided in the form. Obtain necessary signatures from the facility owner or lead interpreting physician.
- Finally, save changes to the completed form. You may download and print a copy for your records or share it per the submission requirements.
Take the next step and fill out the CA CDPH 8623 online today.
The phone number for the California Department of Public Health Licensing and Certification division is available on their website. This direct line allows you to connect with staff who can help answer your questions about CA CDPH 8623. It’s recommended to call during business hours for the best chance of a quick response and effective assistance.
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