Form CDPH4486 "California Genetic Counselor License Application" - California

What Is Form CDPH4486?

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, 2015;
  • 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 CDPH4486 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 CDPH4486 "California Genetic Counselor License Application" - California

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State of California - Health and Human Services Agency
California Department of Public Health
Genetic Disease Screening Program
850 MARINA BAY PARKWAY, F-175
RICHMOND, CA 94804
PHONE: 510/412-1502
FAX: 510/412-1551
Submit by Email
Print Form
CALIFORNIA GENETIC COUNSELOR LICENSE APPLICATION
INSTRUCTIONS: This is an application for a Genetic Counselor License, Temporary Genetic Counselor License or renewal of a Genetic Counselor
License. Please note that the application (CDPH4486) is 3 pages and the payment form (CDPH4487) is 2 pages. The application is designed to be
completed on-line using Acrobat Adobe Reader, or you may may print it out and complete it by hand. In doing so, please type or print neatly. If you do
complete on-line, you may pre-submit your application by pressing the "Submit by Email" button on the upper right hand corner of page one. (Social
security and driver's license numbers are not transmitted via email). By clicking on submit button an email will be sent from your email account to
our email account. If the application is received you will receive an automatic email stating "Thank you for your application." After emailing, you must
then print the application, sign in blue ink and mail the signed copy with any accompanying documents (all attachments are considered part of the
application) along with the license payment paperwork to the Genetic Disease Screening Program, PSQA Branch, at 850 Marina Bay Parkway, F-175,
MS8200, Richmond, CA 94804. Please feel free to call 510-412-1463 or email PSQAGroup@cdph.ca.gov if you have questions or concerns. For more
detailed instructions on the licensure application process, visit www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx.
STANDARD PROCESSING TIME IS ONE TO THREE MONTHS - pre-submitting by email will expedite the process
APPLICANT INFORMATION
LAST NAME
MIDDLE NAME
FIRST NAME
OTHER NAMES YOU HAVE USED
(include Maiden name
DATE OF BIRTH (MM/DD/YYYY)
Photo Area
Affix a 2"x2" Photo
EMAIL ADDRESS
Here
PREFERRED MAILING ADDRESS
(Please include apartment or suite number)
IS ADDRESS HOME OR WORK?
Photo must be of your
head and shoulder
HOME
WORK
areas only and taken
CITY
ZIP
STATE
within 60 days of filing
this application
(NOT transmitted by email)
DRIVER'S LICENSE NUMBER
EXPIRATION DATE (MM/DD/YYYY)
STATE ISSUED
HOME PHONE
(Include area code)
WORK PHONE
(Include area code)
MOBILE PHONE
(Include area code)
FAX PHONE
(Include area code)
WORK PHONE EXTENSION
(NOT transmitted by email)
SOCIAL SECURITY NUMBER
GENDER
ARE YOU A U.S. CITIZEN?
MALE
FEMALE
YES
NO
PLEASE INDICATE HOW YOU WANT YOUR NAME AND DEGREE/S TO APPEAR ON YOUR GENETIC COUNSELOR LICENSE
LICENSE APPLICATION TYPE
SUBMIT GENETIC COUNSELOR CERTIFICATION
YEAR OF CERTIFICATION (YYYY)
GENETIC COUNSELOR LICENSE
CHECK HERE FOR A GENETIC COUNSELOR LICENSE OR IF YOU
DIPLOMATE
DIPLOMATE
ARE AN EXISTING TEMPORARY GENETIC COUNSELOR
OF ABGC
OF ABMG
LICENSEE APPLYING FOR A GENETIC COUNSELOR LICENSE.
DATE OF EXAM (MM/YYYY)
TEMPORARY GENETIC COUNSELOR LICENSE
ACTIVE CANDIDATE OF ABGC?
IF YES, SUBMIT DOCUMENTATION.
IF NO, SEND VERIFICATION OF
TEMPORARY LICENSES ARE FOR THOSE WHO HAVE NOT YET
COMPLETION OF AN ACCREDITED
YES
NO
RECEIVED ABGC CERTIFICATION. THEY ARE ONLY AVAILABLE
GENETIC COUNSELING PROGRAM AND
FOR 2 YEARS AND RENEWALS ARE NOT ALLOWED.
LETTER OF INTENT TO APPLY TO ABGC.
RENEWAL
IF NOT NECESSARY TO
RECERTIFIED
RECERTIFY, CHECK REASON
CHECK HERE FOR A RENEWAL OF YOUR GENETIC COUNSELOR
WITH ABGC
YES
NO
LICENSE. LICENSE MUST BE RENEWED EVERY 3 YEARS. SUBMIT
OR ABMG?
(Submit)
ABGC CERTIFIED
COPIES OF CONTINUING EDUCATION UNITS (CEUs).
PRIOR TO 1996
FOR RENEWALS, PLEASE PROVIDE CURRENT LICENSE NUMBER
PROVIDE MONTH AND YEAR
(MM/YYYY) OF RECERTIFICATION
ABMG CERTIFIED
G C
OR MONTH AND YEAR
PRIOR TO 1993
(MM/YYYY) RECERTIFICATION
DUE
EDUCATION (Renewals need not complete this section)
ABGC, ABGC APPROVED/EQUIVALENT ORGANIZATION OR ABMG ACCREDITED DEGREE PROGRAM
DATES ATTENDED
NAME OF INSTITUTION
DATE EARNED
(NO ABBREVIATIONS OR ACRONYMS)
(MM/YYYY)
FROM (MM/YYYY)
TO (MM/YYYY)
LOCATION
DEGREE
www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx
CDPH 4486 (10/15)
PAGE 1 OF 3
State of California - Health and Human Services Agency
California Department of Public Health
Genetic Disease Screening Program
850 MARINA BAY PARKWAY, F-175
RICHMOND, CA 94804
PHONE: 510/412-1502
FAX: 510/412-1551
Submit by Email
Print Form
CALIFORNIA GENETIC COUNSELOR LICENSE APPLICATION
INSTRUCTIONS: This is an application for a Genetic Counselor License, Temporary Genetic Counselor License or renewal of a Genetic Counselor
License. Please note that the application (CDPH4486) is 3 pages and the payment form (CDPH4487) is 2 pages. The application is designed to be
completed on-line using Acrobat Adobe Reader, or you may may print it out and complete it by hand. In doing so, please type or print neatly. If you do
complete on-line, you may pre-submit your application by pressing the "Submit by Email" button on the upper right hand corner of page one. (Social
security and driver's license numbers are not transmitted via email). By clicking on submit button an email will be sent from your email account to
our email account. If the application is received you will receive an automatic email stating "Thank you for your application." After emailing, you must
then print the application, sign in blue ink and mail the signed copy with any accompanying documents (all attachments are considered part of the
application) along with the license payment paperwork to the Genetic Disease Screening Program, PSQA Branch, at 850 Marina Bay Parkway, F-175,
MS8200, Richmond, CA 94804. Please feel free to call 510-412-1463 or email PSQAGroup@cdph.ca.gov if you have questions or concerns. For more
detailed instructions on the licensure application process, visit www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx.
STANDARD PROCESSING TIME IS ONE TO THREE MONTHS - pre-submitting by email will expedite the process
APPLICANT INFORMATION
LAST NAME
MIDDLE NAME
FIRST NAME
OTHER NAMES YOU HAVE USED
(include Maiden name
DATE OF BIRTH (MM/DD/YYYY)
Photo Area
Affix a 2"x2" Photo
EMAIL ADDRESS
Here
PREFERRED MAILING ADDRESS
(Please include apartment or suite number)
IS ADDRESS HOME OR WORK?
Photo must be of your
head and shoulder
HOME
WORK
areas only and taken
CITY
ZIP
STATE
within 60 days of filing
this application
(NOT transmitted by email)
DRIVER'S LICENSE NUMBER
EXPIRATION DATE (MM/DD/YYYY)
STATE ISSUED
HOME PHONE
(Include area code)
WORK PHONE
(Include area code)
MOBILE PHONE
(Include area code)
FAX PHONE
(Include area code)
WORK PHONE EXTENSION
(NOT transmitted by email)
SOCIAL SECURITY NUMBER
GENDER
ARE YOU A U.S. CITIZEN?
MALE
FEMALE
YES
NO
PLEASE INDICATE HOW YOU WANT YOUR NAME AND DEGREE/S TO APPEAR ON YOUR GENETIC COUNSELOR LICENSE
LICENSE APPLICATION TYPE
SUBMIT GENETIC COUNSELOR CERTIFICATION
YEAR OF CERTIFICATION (YYYY)
GENETIC COUNSELOR LICENSE
CHECK HERE FOR A GENETIC COUNSELOR LICENSE OR IF YOU
DIPLOMATE
DIPLOMATE
ARE AN EXISTING TEMPORARY GENETIC COUNSELOR
OF ABGC
OF ABMG
LICENSEE APPLYING FOR A GENETIC COUNSELOR LICENSE.
DATE OF EXAM (MM/YYYY)
TEMPORARY GENETIC COUNSELOR LICENSE
ACTIVE CANDIDATE OF ABGC?
IF YES, SUBMIT DOCUMENTATION.
IF NO, SEND VERIFICATION OF
TEMPORARY LICENSES ARE FOR THOSE WHO HAVE NOT YET
COMPLETION OF AN ACCREDITED
YES
NO
RECEIVED ABGC CERTIFICATION. THEY ARE ONLY AVAILABLE
GENETIC COUNSELING PROGRAM AND
FOR 2 YEARS AND RENEWALS ARE NOT ALLOWED.
LETTER OF INTENT TO APPLY TO ABGC.
RENEWAL
IF NOT NECESSARY TO
RECERTIFIED
RECERTIFY, CHECK REASON
CHECK HERE FOR A RENEWAL OF YOUR GENETIC COUNSELOR
WITH ABGC
YES
NO
LICENSE. LICENSE MUST BE RENEWED EVERY 3 YEARS. SUBMIT
OR ABMG?
(Submit)
ABGC CERTIFIED
COPIES OF CONTINUING EDUCATION UNITS (CEUs).
PRIOR TO 1996
FOR RENEWALS, PLEASE PROVIDE CURRENT LICENSE NUMBER
PROVIDE MONTH AND YEAR
(MM/YYYY) OF RECERTIFICATION
ABMG CERTIFIED
G C
OR MONTH AND YEAR
PRIOR TO 1993
(MM/YYYY) RECERTIFICATION
DUE
EDUCATION (Renewals need not complete this section)
ABGC, ABGC APPROVED/EQUIVALENT ORGANIZATION OR ABMG ACCREDITED DEGREE PROGRAM
DATES ATTENDED
NAME OF INSTITUTION
DATE EARNED
(NO ABBREVIATIONS OR ACRONYMS)
(MM/YYYY)
FROM (MM/YYYY)
TO (MM/YYYY)
LOCATION
DEGREE
www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx
CDPH 4486 (10/15)
PAGE 1 OF 3
EMPLOYMENT INFORMATION (REQUIRED FOR TEMPORARY APPLICANTS ONLY)
IF NOT CURRENTLY EMPLOYED, ENTER "N/A."
TEMPORARY COUNSELOR LICENSEES ARE REQUIRED TO SUBMIT EMPLOYMENT DETAILS PRIOR TO PRACTICING AS GENETIC COUNSELORS.
EMPLOYER'S NAME
SUPERVISOR'S NAME
SUPERVISOR'S EXTENSION
STREET ADDRESS
(Include suite number)
SUPERVISOR'S PHONE NUMBER
(Include area code)
CITY
STATE
ZIP
SUPERVISOR'S
MD
LICENSED GENETIC COUNSELOR
POSITION
LICENSE HISTORY
IF YES, PLEASE GIVE DATE PREVIOUS
HAVE YOU EVER FILED AN APPLICATION FOR A GENETIC COUNSELOR
APPLICATION WAS SUBMITTED
YES
NO
OR A TEMPORARY GENETIC COUNSELOR LICENSE IN CALIFORNIA?
(MM/YYYY). IF MORE THAN ONCE,
GIVE MOST RECENT DATE.
IF YES,
HAS THIS LICENSE EVER
DO YOU HOLD OR HAVE YOU
PROVIDE
PROFESSION:
BEEN REVOKED OR
HELD ANY OTHER
YES
NO
PROFESSION,
SUBJECT TO DISCIPLINE?
PROFESSIONAL LICENSE (MD,
LICENSE
RN, NP, GC) IN ANY STATE,
NUMBER AND
TERRITORY, PROVINCE,
LICENSE
IF YES, PLEASE PROVIDE COPIES OF ALL OFFICIAL
JURISDICTION
COUNTRY, OR U.S. FEDERAL
NUMBER:
DOCUMENTATION REGARDING THE MATTER IN
(IF MORE
JURISDICTION?
ADDITION TO A WRITTEN EXPLANATION. YOU ARE
THAN ONE
ALSO REQUIRED TO REPORT ANY MATTER THAT IS
PROFESSION,
YES
NO
PENDING OR IN WHICH CHARGES HAVE BEEN
GIVE MOST
JURISDICTION:
DROPPED OR EXPUNGED.
RELEVANT)
LIST ALL GENETIC COUNSELOR OR TEMPORARY GENETIC COUNSELOR LICENSES THAT HAVE EVER BEEN ISSUED TO YOU BY ANY STATE OR JURISDICTION
DATE OF ISSUANCE
DATES OF PRACTICE IN STATE/JURISDICTION
STATE/JURISDICTION
LICENSE NUMBER
(MM/YYYY)
FROM (MM/YYYY)
TO (MM/YYYY)
BACKGROUND
IF YOU ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS, PLEASE PROVIDE ALL OFFICIAL DOCUMENTATION REGARDING THE MATTER
IN ADDITION TO A WRITTEN PERSONAL EXPLANATION. AN APPLICANT MUST PROVIDE OFFICIAL HEARING/COURT DOCUMENTS AND
LETTERS OF EXPLANATION FROM THE GENETIC COUNSELING CERTIFYING BODY.
IF THESE DOCUMENTS ARE NOT PROVIDED WITH THE MAILED APPLICATION, THEY WILL BE REQUESTED AND REVIEW OF THE APPLICATION
WILL NOT PROCEED UNTIL DOCUMENTS ARE RECEIVED. APPLICANTS ARE REQUIRED TO REPORT ANY MATTER THAT IS PENDING OR IN
WHICH CHARGES HAVE BEEN DROPPED OR EXPUNGED.
1.
DO YOU HAVE ANY HISTORY OF DISCIPLINARY ACTION BY THE ABGC OR ABMG?
YES
NO
FOR ALL THE QUESTIONS BELOW, INCLUDE ANY DISCIPLINARY ACTIONS BY THE U.S. MILITARY, U.S. PUBLIC HEALTH SERVICE, OR OTHER FEDERAL
GOVERNMENT ENTITY.
2.
HAVE YOU EVER BEEN CHARGED WITH, OR BEEN FOUND TO HAVE COMMITTED UNPROFESSIONAL CONDUCT, INCLUDING INCOMPETENCE,
GROSS NEGLIGENCE IN PERFORMING GENETIC COUNSELOR SERVICES, OR HAVE BEEN DETERMINED TO NOT ADEQUATELY DEMONSTRATE
YES
NO
THAT YOU HAVE BEEN REHABILITATED AND WILL PRESENT A THREAT TO THE HEALTH, SAFETY, OR WELFARE OF PATIENTS?
3.
HAVE YOU EVER KNOWINGLY MADE FALSE STATEMENTS OF FACT ON AN APPLICATION OR OMITTED FACTS THAT WOULD HAVE RESULTED IN
YES
NO
THE DENIAL OF A GENETIC COUNSELOR OR TEMPORARY GENETIC COUNSELOR LICENSE?
4.
HAVE YOU EVER USED THE TITLE GENETIC COUNSELOR OR ANY OTHER TITLE IMPLYING THAT YOU WERE LICENSED AS A GENETIC COUNSELOR
YES
NO
OR TEMPORARY GENETIC COUNSELOR WITHOUT OBTAINING SUCH LICENSE BY THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH AFTER
RECEIVING A WARNING TO CEASE SUCH USE?
5.
HAVE YOU COMMITTED A DELIBERATE BREACH OF CONFIDENTIALITY OF PATIENT INFORMATION, OR COMMITTED A BREACH OF CONFIDENTIALITY
YES
NO
SUBJECT TO SECTION 124980 OF THE HEALTH AND SAFETY CODE?
6.
HAVE YOU BEEN DENIED A GENETIC COUNSELOR LICENSE OR TEMPORARY GENETIC COUNSELOR LICENSE, PERMISSION TO PRACTICE GENETIC
YES
NO
COUNSELING, OR PERMISSION TO TAKE A GENETIC COUNSELOR LICENSE EXAMINATION IN ANY STATE, TERRITORY, COUNTRY, OR U.S. FEDERAL
JURISDICTION?
CDPH 4486 (10/15)
PAGE 2 OF 3
www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx
BACKGROUND - continued
YES
NO
7.
HAVE YOU EVER HAD TO SURRENDER YOUR LICENSE TO PRACTICE GENETIC COUNSELING IN CALIFORNIA OR ANY OTHER STATE?
8.
HAVE YOU EVER BEEN CONVICTED OF A FELONY CHARGE SUBSTANTIALLY RELATED TO THE QUALIFICATIONS, FUNCTIONS, OR DUTIES OF A
YES
NO
GENETIC COUNSELOR? A VERDICT OF GUILTY OR A PLEA OF GUILTY OR NOLO CONTENDERE TO A FELONY CHARGE IS DEEMED A CONVICTION.
9.
IS ANY CRIMINAL ACTION RELATED TO THE ABOVE PENDING?
YES
NO
APPLICATION DECLARATION/SIGNATURE
I HEREBY CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA TO THE TRUTH AND ACCURACY OF ALL STATEMENTS,
ANSWERS AND REPRESENTATIONS MADE IN THIS APPLICATION, INCLUDING ALL SUPPLEMENTARY STATEMENTS. I ALSO CERTIFY THAT I PERSONALLY
COMPLETED THIS APPLICATION AND HAVE READ AND UNDERSTAND THE INSTRUCTIONS. I UNDERSTAND THAT FALSIFICATION OR MISREPRESENTATION OF
ANY ITEM OR RESPONSE ON THIS APPLICATION OR ANY ATTACHMENT HERETO IS A SUFFICIENT BASIS FOR DENYING OR REVOKING A LICENSE.
SIGNATURE OF APPLICANT
PLEASE SIGN FULL NAME IN BLUE INK
SIGNED ON THIS
DAY OF
MONTH (SPELL OUT)
YEAR (YYYY)
(DD)
PRIVACY DETAILS AND RIGHTS
* MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBER
DISCLOSURE OF YOUR U.S. SOCIAL SECURITY NUMBER IS MANDATORY. SECTION 17520 OF THE FAMILY CODE, SECTION 494.5 OF THE BUSINESS AND PROFESSIONS CODE, AND PUBLIC
LAW 94-455 (42 USCA 405 (c)(2)(C)) AUTHORIZE COLLECTION OF YOUR SOCIAL SECURITY NUMBER. IF YOU FAIL TO DISCLOSE YOUR SOCIAL SECURITY NUMBER YOUR APPLICATION FOR
LICENSURE WILL NOT BE PROCESSED.
NOTICE OF INFORMATION PRACTICES PRIVACY NOTIFICATION
THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH IS AUTHORIZED TO COLLECT INFORMATION UNDER THE HEALTH AND SAFETY CODE SECTIONS 124980, 124981 AND 124982, FAMILY
CODE SECTION 17520, AND BUSINESS AND PROFESSIONS CODE SECTION 494.5. THIS INFORMATION IS USED TO IDENTIFY A PERSON APPLYING FOR A TEMPORARY GENETIC
COUNSELOR LICENSE, GENETIC COUNSELOR LICENSE OR RENEWAL OF A GENETIC COUNSELOR LICENSE.
USES AND DISCLOSURE OF INFORMATION
CALIFORNIA LAW ALLOWS THE DEPARTMENT OF CHILD SUPPORT SERVICES, THE STATE BOARD OF EQUALIZATION, AND THE FRANCHISE TAX BOARD TO SHARE TAXPAYER
INFORMATION WITH THE DEPARTMENT OF PUBLIC HEALTH AND REQUIRES THE LICENSEE TO PAY HIS OR HER CHILD SUPPORT OR STATE TAX OBLIGATIONS. A LICENSE MAY BE
DENIED OR SUSPENDED IF THE CHILD SUPPORT OR STATE TAX OBLIGATIONS ARE NOT PAID.
THE STATE WILL PROVIDE THE PUBLIC WITH A LIST OF INDIVIDUALS WITH VALID GENETIC COUNSELOR LICENSES. THE INFORMATION YOU PROVIDE FOR YOUR LICENSE IS
CONFIDENTIAL AND WILL NOT BE RELEASED WITHOUT YOUR WRITTEN PERMISSION. SUBJECT TO CERTAIN REQUIREMENTS, WE MAY GIVE OUT YOUR INFORMATION WITHOUT YOUR
AUTHORIZATION FOR AUDITING PURPOSES, FOR VERIFICATION OF ABGC OR ABMG CERTIFICATION STATUS, AND FOR THE PURPOSES OF MATCHING NAMES WITH CERTIFIED LISTS
OF CHILD SUPPORT OBLIGERS FOUND TO BE OUT OF COMPLIANCE WITH A JUDGMENT OR ORDER FOR SUPPORT PURSUANT TO SECTION 17520 OF THE FAMILY CODE, AND OF THE
LARGEST TAX DELINQUENCIES PURSUANT TO SECTION 494.5 OF THE BUSINESS AND PROFESSIONS CODE. WE PROVIDE INFORMATION WHEN OTHERWISE REQUIRED BY LAW, SUCH
AS FOR LAW ENFORCEMENT IN SPECIFIC CIRCUMSTANCES. IN ANY OTHER SITUATION, WE WILL ASK FOR YOUR WRITTEN AUTHORIZATION BEFORE USING OR DISCLOSING ANY
IDENTIFIABLE INFORMATION. IF YOU CHOOSE TO SIGN AN AUTHORIZATION TO DISCLOSE INFORMATION, YOU CAN LATER REVOKE THAT AUTHORIZATION TO STOP ANY FUTURE USES
AND DISCLOSURES.
INDIVIDUAL RIGHTS
YOU HAVE THE RIGHT TO LOOK AT OR RECEIVE A COPY OF YOUR INFORMATION. IF YOU REQUEST COPIES, WE WILL CHARGE YOU $0.05 (5 CENTS) FOR EACH PAGE. YOU ALSO HAVE
THE RIGHT TO RECEIVE A LIST OF INSTANCES WHERE WE HAVE DISCLOSED INFORMATION ABOUT YOU. IF YOU BELIEVE THAT INFORMATION IN YOUR RECORD IS INCORRECT OR IF
IMPORTANT INFORMATION IS MISSING, YOU HAVE THE RIGHT TO REQUEST THAT WE CORRECT THE EXISTING INFORMATION OR ADD THE MISSING INFORMATION. PLEASE CONTACT
THE CHIEF, GENETIC DISEASE SCREENING PROGRAM, 850 MARINA BAY PARKWAY F-175, RICHMOND, CALIFORNIA 94804. TELEPHONE 510/412-1502, FAX 510/412-1551.
COMPLAINTS
IF YOU ARE CONCERNED THAT WE HAVE VIOLATED YOUR PRIVACY RIGHTS, OR YOU DISAGREE WITH A DECISION WE MADE ABOUT ACCESS TO YOUR INFORMATION, YOU MAY
CONTACT THE GENETIC DISEASE SCREENING PROGRAM. YOU ALSO MAY SEND A WRITTEN COMPLAINT TO THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. THE GENETIC
DISEASE SCREENING PROGRAM CAN PROVIDE YOU WITH THE CONTACT INFORMATION FOR THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.
OUR LEGAL DUTY
WE ARE REQUIRED BY FEDERAL AND STATE LAW TO PROTECT THE PRIVACY OF YOUR INFORMATION, PROVIDE THIS NOTICE ABOUT OUR INFORMATION PRACTICES, AND FOLLOW THE
INFORMATION PRACTICES THAT ARE DESCRIBED IN THIS NOTICE. FOR ANY REQUEST FOR INFORMATION OR ACTION WITH RESPECT TO YOUR RECORDS MAINTAINED BY THE
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, PLEASE CONTACT: CHIEF, GENETIC DISEASE SCREENING PROGRAM, 850 MARINA BAY PARKWAY F-175, RICHMOND, CALIFORNIA 94804.
TELEPHONE 510/412-1502, FAX 510/412-1551.
FOR DEPT. USE ONLY
DATE APPLICATION RECEIVED
DATE LICENSE ISSUED:
LICENSE NUMBER ISSUED:
G C
CDPH 4486 (10/15)
PAGE 3 OF 3
www.cdph.ca.gov/programs/GDSP/Pages/GeneticCounselorWebpage.aspx
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