Form CDPH8217 SRA III "Physician Assistant Fluoroscopy Permit Renewal" - California

What Is Form CDPH8217 SRA III?

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 May 1, 2020;
  • 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 CDPH8217 SRA III 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 CDPH8217 SRA III "Physician Assistant Fluoroscopy Permit Renewal" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Renewals will not be considered complete until both the renewal payment and continuing education
credits have been received by the department.
Physician Assistant Fluoroscopy Renewal Check List:
1. Renewal Payment:
Return the completed Special Renewal Application (page 2) along with your nonrefundable renewal
payment in the form of a check or money order made payable to “CDPH-RHB”. The fees are as
follows:
$154.00 if your certificate has not expired.
$170.00 if your certificate expired within the past six months.
$324.00 if your certificate expired within the past 5½ years.
Note: Certificates cannot be renewed after 5½ years from the expiration date. You will need to reapply.
2. Continuing Education Credits:
An approved continuing education credit is one hour of instruction received in subjects related to the
application of X-ray to the human body and accepted for purposes of credentialing, assigning
professional status, or certification. You are required to earn 10 approved continuing education credits
within the past two years.
 Physician Assistant Fluoroscopy permit holders are required to earn four of the ten credits in
radiation safety for the clinical uses of fluoroscopy.
For further information on continuing education credit requirements, you may visit
RHB Continuing Education Credits Requirements Page
. Failure to provide a complete renewal, will
delay the update of your certificate.
Do not submit copies of your certificates. You are required to maintain proof of continuing education
for four years, to be provided upon request.
Mail your renewal payment and continuing education credits to:
3.
Mailing Address:
Express Mail:
CDPH-Radiologic Health Branch
CDPH-Radiologic Health Branch
Billing/Cashiering, MS 7610
Billing/Cashiering, MS 7610
P.O. Box 997414
1500 Capitol Avenue
Sacramento, CA 95899-7414
Sacramento, CA 95814-5006
A valid temporary authorization will be available to view and print for work purposes, within 24-48 hours
after your completed renewal is processed, at
RHB Certificate/Permit Search Tool
.
CDPH 8217 SRA III (Rev. 05/2020)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Renewals will not be considered complete until both the renewal payment and continuing education
credits have been received by the department.
Physician Assistant Fluoroscopy Renewal Check List:
1. Renewal Payment:
Return the completed Special Renewal Application (page 2) along with your nonrefundable renewal
payment in the form of a check or money order made payable to “CDPH-RHB”. The fees are as
follows:
$154.00 if your certificate has not expired.
$170.00 if your certificate expired within the past six months.
$324.00 if your certificate expired within the past 5½ years.
Note: Certificates cannot be renewed after 5½ years from the expiration date. You will need to reapply.
2. Continuing Education Credits:
An approved continuing education credit is one hour of instruction received in subjects related to the
application of X-ray to the human body and accepted for purposes of credentialing, assigning
professional status, or certification. You are required to earn 10 approved continuing education credits
within the past two years.
 Physician Assistant Fluoroscopy permit holders are required to earn four of the ten credits in
radiation safety for the clinical uses of fluoroscopy.
For further information on continuing education credit requirements, you may visit
RHB Continuing Education Credits Requirements Page
. Failure to provide a complete renewal, will
delay the update of your certificate.
Do not submit copies of your certificates. You are required to maintain proof of continuing education
for four years, to be provided upon request.
Mail your renewal payment and continuing education credits to:
3.
Mailing Address:
Express Mail:
CDPH-Radiologic Health Branch
CDPH-Radiologic Health Branch
Billing/Cashiering, MS 7610
Billing/Cashiering, MS 7610
P.O. Box 997414
1500 Capitol Avenue
Sacramento, CA 95899-7414
Sacramento, CA 95814-5006
A valid temporary authorization will be available to view and print for work purposes, within 24-48 hours
after your completed renewal is processed, at
RHB Certificate/Permit Search Tool
.
CDPH 8217 SRA III (Rev. 05/2020)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
SPECIAL RENEWAL APPLICATION
Physician Assistant Fluoroscopy Permit
Permit Number
Permit Expiration Date
Phone Number
Last Name, Suffix
First Name
Middle Name
Social Security Number / ITIN
Date of Birth (MM/DD/YYYY)
Email Address
Mailing Address or P.O. Box Number
Check if you are requesting to change your address
City
State
Zip Code
Name change requests must be accompanied by a copy of a certified superior court order allowing the name change
and a government issued picture ID, such as a driver’s license, military ID, or passport. The information you provide
on this form may be made public by the California Public Records Act; please provide a P.O. Box number or other
alternate address and/or an alternate phone number if you do not wish to have your home address and/or phone
number made public.
Physician Assistant License Number
Expiration Date
Please list your 10 required credits in the space provided below, accordingly. Complete extra copies
of this application as needed to list the approved continuing education credits you have earned.
Indicate the certifying organization letter below in “Group” *: (a) American Registry of Radiologic
Technologists (ARRT), (b) Medical Board of California, (c) Osteopathic Medical Board of California,
(d) Podiatric Medical Board of California, (e) California Board of Chiropractic Examiners, (f) Dental Board of
California.
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
Select
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
Select
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
Select
REQUEST FOR CANCELLATION (Optional)
Please note: If you request to cancel your permit, you are not eligible for reinstatement and will need to
reapply for a new permit.
I wish to cancel my permit. (Do not submit payment)
I certify that the information provided in this application for renewal is true and correct. I understand that the California
Department of Public Health may revoke certificates or permits that are procured by fraud, misrepresentation, or mistake, or 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, I am acting within the scope of that certification.
Signature (Original Signature Required)
Date
CDPH 8217 SRA III (Rev. 05/2020)
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