Form CDPH261 "Application for Physical Therapy Service" - California

What Is Form CDPH261?

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 October 1, 2008;
  • 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 CDPH261 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 CDPH261 "Application for Physical Therapy Service" - California

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR
Reply
to:
PHYSICAL THERAPY SERVICE
_______________________________
HOSPITAL NAME
1. Name and qualifications of the physical therapist responsible for the service: __________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Number of full-time physical therapists assigned to the service:
______________
3. Number of part-time physical therapists assigned to the service:
______________
4. Number
of physical therapy assistants:
______________
5. Number
of physical therapy aides:
______________
6. Number
of treatments provided annually:
______________
CDPH 261 (10/08)
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR
Reply
to:
PHYSICAL THERAPY SERVICE
_______________________________
HOSPITAL NAME
1. Name and qualifications of the physical therapist responsible for the service: __________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Number of full-time physical therapists assigned to the service:
______________
3. Number of part-time physical therapists assigned to the service:
______________
4. Number
of physical therapy assistants:
______________
5. Number
of physical therapy aides:
______________
6. Number
of treatments provided annually:
______________
CDPH 261 (10/08)