Form PM210 "Registration of Agency Intending to Provide Hearing Testing Services" - California

What Is Form PM210?

This is a legal form that was released by the California Department of Health Care Services - 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, 2015;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form PM210 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form PM210 "Registration of Agency Intending to Provide Hearing Testing Services" - California

114 times
Rate (4.7 / 5) 7 votes
State of California—Health and Human Services Agency
Department of Health Care Services
Systems of Care Division
Return to:
California Department of Health Care Services
FOR DEPARTMENT USE
Systems of Care Division
Hearing Conservation Program
Registration accepted
Yes
No
MS 8103
Date
Initials
P.O. Box 997413
Sacramento, CA 95899-7413
Attention: Health Program Specialist
REGISTRATION OF AGENCY INTENDING TO PROVIDE
HEARING TESTING SERVICES
Pursuant to Section 49452, California Education Code, the current Guidelines for Authorization by the County Superintendent(s)
of Schools and the current hearing testing standards, as prescribed by Section 2951, California Code of Regulations, Title 17
(Health), we submit herewith, for acceptance and registration the following description of our services, facilities, and personnel.
Name of agency or private provider
County
Address
City
ZIP code
Telephone Number
Email Address
Date
Director’s name
Degree
Licensed physician
California Credential—Speech/Hearing
Licensed audiologist
California Credential—School Nurse
Description of testing services, facilities, special equipment:
All hearing testing services shall meet or exceed the standards prescribed by the California Code of Regulations,
Title 17, Section 2951.
THE FOLLOWING PERSONNEL WILL CONDUCT TESTING SERVICES
QUALIFICATIONS
Number
Number
Number
Speech/
NAME
ADDRESS
Licensed
School
Hearing
Audiologist
Audiometrist
Specialist
CHANGES IN PERSONNEL WILL BE REPORTED TO THE DEPARTMENT WITHIN TEN DAYS.
Director’s signature
Degree
Title
Date
PM 210 (05/15)
State of California—Health and Human Services Agency
Department of Health Care Services
Systems of Care Division
Return to:
California Department of Health Care Services
FOR DEPARTMENT USE
Systems of Care Division
Hearing Conservation Program
Registration accepted
Yes
No
MS 8103
Date
Initials
P.O. Box 997413
Sacramento, CA 95899-7413
Attention: Health Program Specialist
REGISTRATION OF AGENCY INTENDING TO PROVIDE
HEARING TESTING SERVICES
Pursuant to Section 49452, California Education Code, the current Guidelines for Authorization by the County Superintendent(s)
of Schools and the current hearing testing standards, as prescribed by Section 2951, California Code of Regulations, Title 17
(Health), we submit herewith, for acceptance and registration the following description of our services, facilities, and personnel.
Name of agency or private provider
County
Address
City
ZIP code
Telephone Number
Email Address
Date
Director’s name
Degree
Licensed physician
California Credential—Speech/Hearing
Licensed audiologist
California Credential—School Nurse
Description of testing services, facilities, special equipment:
All hearing testing services shall meet or exceed the standards prescribed by the California Code of Regulations,
Title 17, Section 2951.
THE FOLLOWING PERSONNEL WILL CONDUCT TESTING SERVICES
QUALIFICATIONS
Number
Number
Number
Speech/
NAME
ADDRESS
Licensed
School
Hearing
Audiologist
Audiometrist
Specialist
CHANGES IN PERSONNEL WILL BE REPORTED TO THE DEPARTMENT WITHIN TEN DAYS.
Director’s signature
Degree
Title
Date
PM 210 (05/15)