Form CDPH8231 "California Radiology Supervisor and Operator Application (For Radiologists and Radiation Oncologists Only)" - California

What Is Form CDPH8231?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8231 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8231 "California Radiology Supervisor and Operator Application (For Radiologists and Radiation Oncologists Only)" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
California Radiology Supervisor and Operator Certificate Application
(For Radiologists and Radiation Oncologists ONLY)
Last Name (Please Print)
First Name
Middle Name
SSN or ITIN*
Date of Birth
Phone Number
Mailing Address (Number and Street or P.O. Box Number)
E-mail Address
City
State
Zip Code
*Social Security Number or Individual Taxpayer Identification Number
Pursuant to the authority found in Section 114870 of the California Health and Safety Code and as
required by Section 17520 of the California Family Code, providing the SSN/ITIN is mandatory. The
SSN/ITIN will be used for purposes of identification. The information on this form may be provided to
federal, state, or local agencies for law enforcement purposes. The information you provide on this
form (except for SSN/ITIN) may be made public under the California Public Records Act; please
provide a P.O. Box number or other alternate address if you do not wish to have your home address
made public. This information may also be provided to the American Registry of Radiologic
Technologists (ARRT) for examination purposes. For information or access to your records, contact
the Certification Support Unit at the California Department of Public Health, Radiologic Health Branch
(CDPH-RHB), MS 7610, P.O. Box 997414, Sacramento, CA 95899-7414, (916) 327-5106.
IMPORTANT: A radiology supervisor and operator certificate issued by the Department shall
be required of and issued only to any licentiate of the healing arts who practices as a
radiologist or radiation oncologist in accordance with the California Code of Regulations, title
17, section 30466. For all others, do not complete this application. Please refer to the
California Licentiate Supervisor and Operator Permits application form CDPH 8230.
REQUIREMENTS TO OBTAIN A RADIOLOGY SUPERVISOR AND OPERATOR CERTIFICATE
You must submit this application along with documentary evidence of meeting one of the
following:
Board certification by the American Board of Radiology (ABR) or American Osteopathic Board of
Radiology (AOBR); or
You have passed ABR’s:
(ONLY a Verification Letter from ABR is acceptable)
1) Diagnostic radiology initial qualifying physics examination and the diagnostic radiology
initial qualifying clinical examination;
2) Diagnostic radiology core exam; or
3) Radiation oncology initial qualifying physics examination, the initial qualifying cancer
biology examination, and the initial qualifying clinical examination; or
CDPH 8231 (3/19)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
California Radiology Supervisor and Operator Certificate Application
(For Radiologists and Radiation Oncologists ONLY)
Last Name (Please Print)
First Name
Middle Name
SSN or ITIN*
Date of Birth
Phone Number
Mailing Address (Number and Street or P.O. Box Number)
E-mail Address
City
State
Zip Code
*Social Security Number or Individual Taxpayer Identification Number
Pursuant to the authority found in Section 114870 of the California Health and Safety Code and as
required by Section 17520 of the California Family Code, providing the SSN/ITIN is mandatory. The
SSN/ITIN will be used for purposes of identification. The information on this form may be provided to
federal, state, or local agencies for law enforcement purposes. The information you provide on this
form (except for SSN/ITIN) may be made public under the California Public Records Act; please
provide a P.O. Box number or other alternate address if you do not wish to have your home address
made public. This information may also be provided to the American Registry of Radiologic
Technologists (ARRT) for examination purposes. For information or access to your records, contact
the Certification Support Unit at the California Department of Public Health, Radiologic Health Branch
(CDPH-RHB), MS 7610, P.O. Box 997414, Sacramento, CA 95899-7414, (916) 327-5106.
IMPORTANT: A radiology supervisor and operator certificate issued by the Department shall
be required of and issued only to any licentiate of the healing arts who practices as a
radiologist or radiation oncologist in accordance with the California Code of Regulations, title
17, section 30466. For all others, do not complete this application. Please refer to the
California Licentiate Supervisor and Operator Permits application form CDPH 8230.
REQUIREMENTS TO OBTAIN A RADIOLOGY SUPERVISOR AND OPERATOR CERTIFICATE
You must submit this application along with documentary evidence of meeting one of the
following:
Board certification by the American Board of Radiology (ABR) or American Osteopathic Board of
Radiology (AOBR); or
You have passed ABR’s:
(ONLY a Verification Letter from ABR is acceptable)
1) Diagnostic radiology initial qualifying physics examination and the diagnostic radiology
initial qualifying clinical examination;
2) Diagnostic radiology core exam; or
3) Radiation oncology initial qualifying physics examination, the initial qualifying cancer
biology examination, and the initial qualifying clinical examination; or
CDPH 8231 (3/19)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Last Name (Please Print)
First Name
Middle Name
You have passed AOBR’s:
1) Part I (Physics of Medical Imaging, Biological Effects and Safety) and Part II (Diagnostic
Imaging) examinations in diagnostic radiology; or
2) Part I (Radiobiology), Part II (Physics), and Part III (Clinical) examinations in radiation
oncology.
In addition, you must also return the completed application with both of the following:
• A copy of one of the following valid California healing arts licenses: Physician and Surgeon, or
Osteopathic Physician and Surgeon; and
• The non-refundable application fee of $127.00 in the form of a check (e.g., personal, cashier’s,
or certified check) or money order made payable to CDPH-RHB
Please mail this application, all supporting documents, and the non-refundable application fee
of $127.00 to:
USPS First-Class Mail:
Express Mail:
California Department of Public Health
California Department of Public Health
Radiologic Health Branch, MS 7610
Radiologic Health Branch, MS 7610
Accounts Receivable and Cashiering Unit
Accounts Receivable and Cashiering Unit
P.O. Box 997414
1500 Capitol Ave., Suite 520, Bldg. 172
Sacramento, CA 95899-7414, or
Sacramento, CA 95814-5006
NOTIFICATION OF APPLICATION STATUS
Within 30 calendar days of receipt of your application, CDPH-RHB will mail you a notification letter.
The notification letter will inform you of one of the following:
• That your application is complete; or
• That your application is not acceptable for filing and next steps.
I certify under penalty of perjury that the information provided with this application is true and correct.
I understand that the California Department of Public Health may cancel certificates that are procured
by fraud, misrepresentation, or mistake, and may revoke certificates for the nonpayment of fees.
Further, I am aware that it is unlawful to use X-rays on human beings in this state unless I am
certified pursuant to the Radiologic Technology Act and acting within the scope of that certification. In
addition, by signing below, I am attesting that I practice as a radiologist or radiation oncologist.
Signature
Date
CDPH 8231 (3/19)
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