Form CDPH508 "Application to Become a Provider of Continuing Education" - California

What Is Form CDPH508?

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, 2013;
  • 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;

Download a fillable version of Form CDPH508 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 CDPH508 "Application to Become a Provider of Continuing Education" - California

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State of California – Health and Human Services Agency
California Department of Public Health (CDPH)
Nursing Home Administrator Program (NHAP)
MS 3302, P.O. BOX 997416
Sacramento, CA 95899-7416
(916) 552-8780 FAX: (916) 552-8777
NHAP@cdph.ca.gov
APPLICATION TO BECOME A PROVIDER
OF CONTINUING EDUCATION
Instructions: 1. Submit this application in duplicate. (photocopies accepted)
2. Include a check or money order (made payable to NHAP) with the appropriate
FOR OFFICE USE ONLY
fees to the following address:
Cash #
Nursing Home Administrator Program
Amount
MS 3302, P.O. Box 997416
NHAP Staff Initials
Sacramento, CA 95899-7416
3. Refer to the Guideline for Approval of Continuing Education Providers and Courses.
4. Please visit our website at
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
to view the current fee list and
Guideline for Approval of Continuing Education Providers and Courses.
Name of Provider:
Phone #:
Business Address:
SSN, Acct. # or FIEN:
(Provider certificates cannot be issued without
this number. Does not apply to partnerships.)
Provider is a/an:
Individual
University, College or School
Health Association
Partnership
Health Facility
Corporation
Government Agency
Other: ________________________________
Print below the name and title of: if an individual, the individual applying: if a partnership, the members thereof; if a corporation, association or other type
of organization, the president, vice-president and secretary.
Name:
Title:
Name:
Title:
Name:
Title:
Name, title and mailing address of person to whom all correspondence should be directed:
Name:
Title:
Signature:
Date:
Maintenance of the information requested on this application form is authorized by the Health and Safety Code 1416. No items of information are
voluntary; all are required. Failure to provide any of the requested information will result in the rejection of the application.
*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code section 17520, subdivision (d), the California Department of Public Health (CDPH) is
required to collect social security numbers from all applicants for nursing home administrator licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child
support orders upon request by the Department of Child Support Services and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR, Section 61.1 et seq. Failure to
provide your social security number will result in the return of your application. Your social security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify
certification with another state’s certification authority, for exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.
DO NOT WRITE BELOW THIS LINE
Provider #:
Approved by:
Application has been provided
Date:
Approval Expires:
Denied by:
Date:
Application has been denied:
Reason for denial:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CDPH 508 (10/13)
State of California – Health and Human Services Agency
California Department of Public Health (CDPH)
Nursing Home Administrator Program (NHAP)
MS 3302, P.O. BOX 997416
Sacramento, CA 95899-7416
(916) 552-8780 FAX: (916) 552-8777
NHAP@cdph.ca.gov
APPLICATION TO BECOME A PROVIDER
OF CONTINUING EDUCATION
Instructions: 1. Submit this application in duplicate. (photocopies accepted)
2. Include a check or money order (made payable to NHAP) with the appropriate
FOR OFFICE USE ONLY
fees to the following address:
Cash #
Nursing Home Administrator Program
Amount
MS 3302, P.O. Box 997416
NHAP Staff Initials
Sacramento, CA 95899-7416
3. Refer to the Guideline for Approval of Continuing Education Providers and Courses.
4. Please visit our website at
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
to view the current fee list and
Guideline for Approval of Continuing Education Providers and Courses.
Name of Provider:
Phone #:
Business Address:
SSN, Acct. # or FIEN:
(Provider certificates cannot be issued without
this number. Does not apply to partnerships.)
Provider is a/an:
Individual
University, College or School
Health Association
Partnership
Health Facility
Corporation
Government Agency
Other: ________________________________
Print below the name and title of: if an individual, the individual applying: if a partnership, the members thereof; if a corporation, association or other type
of organization, the president, vice-president and secretary.
Name:
Title:
Name:
Title:
Name:
Title:
Name, title and mailing address of person to whom all correspondence should be directed:
Name:
Title:
Signature:
Date:
Maintenance of the information requested on this application form is authorized by the Health and Safety Code 1416. No items of information are
voluntary; all are required. Failure to provide any of the requested information will result in the rejection of the application.
*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code section 17520, subdivision (d), the California Department of Public Health (CDPH) is
required to collect social security numbers from all applicants for nursing home administrator licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child
support orders upon request by the Department of Child Support Services and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR, Section 61.1 et seq. Failure to
provide your social security number will result in the return of your application. Your social security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify
certification with another state’s certification authority, for exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.
DO NOT WRITE BELOW THIS LINE
Provider #:
Approved by:
Application has been provided
Date:
Approval Expires:
Denied by:
Date:
Application has been denied:
Reason for denial:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CDPH 508 (10/13)