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Application For Home Medical Device Retailer Exemptee License-New And Renewal DHS 8695 - California
| Application For Home Medical Device Retailer Exemptee License-New And Renewal Form. This is a California form and can be used in Food And Drug Department Of Health And Human Services Statewide . |
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State of California--Health and Human Services Agency California Department of Public Health Food and Drug Branch APPLICATION FOR HOME MEDICAL DEVICE RETAILER EXEMPTEE LICENSE NEW AND RENEWAL License Number: Date Received: CID # Amount: $ PLEASE DO NOT WRITE ABOVE THIS LINE Read instructions on attached sheet. Unsigned or incomplete applications will not be processed. New Exemptee 1. Legal Name of Applicant: Residence address: Home phone number: ( ) Last Relocation First City Additional License Middle State Renewal Former Zip Code Number and Street Date of birth: If Renewal, Exemptee license No: 2. Name of HMDR facility where Exemptee will be working and / Business days and hours when Exemptee will be dispensing or distributing: Address of HMDR facility: Work phone number: ( ) Number and Street City State Expiration date: Zip Code HMDR license number of employer (leave blank if unknown): 3. Contact Name (if different from exemptee name): 4. Mailing Address (if different from HMDR facility): City State Zip Code 5. Has the applicant ever been convicted of a felony? 6. Yes No If "yes," provide an explanation on a separate sheet. (The following questions are for NEW APPLICANTS ONLY) Please provide the following information to determine if you meet the minimum qualifications. Do you have a high school diploma or equivalent? (Attach a copy) Yes No Has your current employer provided you with on-the-job training specific to your duties? (Attach records) Yes No Do you hold any of the following professional certifications or licenses: (Attach a copy) Respiratory Therapist LVN RN PT OT Pharmacy Technician Other Have you had one year or more paid experience related to the distribution or dispensing of dangerous drugs or dangerous Yes No devices? (Provide proof of 1 year experience) Have you completed training program(s) that address the following: (Attach copy of completed training certificate) State and Federal laws relating to the distribution of dangerous drugs and dangerous devices? State and Federal laws relating to the distribution of controlled substances? The United States Pharmacopoeia standards relating to the safe storage and handling of drugs? The safe storage and handling of home medical devices? Prescription terminology, abbreviations, and format? Yes Yes Yes Yes Yes No No No No No For all of the above questions answered yes, you must submit appropriate proof to verify qualifications. 7. Certification of Exemptee - Please read carefully and sign below I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license. 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 attached to this application. Applicant Exemptee signature: (in full, no initials) CDPH 8695 (09/09) Date: PCA 76223 Receipt Source 125700 Agency Source 49 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Fund Code 3018 Index 5624 State of California--Health and Human Services Agency California Department of Public Health Food and Drug Branch THIS AREA IS TO BE COMPLETED BY THE EMPLOYER 8. Legal Name of Home Medical Device Retailer: Business name: (if different) Facility Address: Number and Street City State Zip Code HMDR license number: 9. The applicant medical device retailer will sell the following products: (Check all that apply) Respiratory Equipment / O2 Supplies CPAPS, BiPAPS TENS Units Infusion Pumps Catheters CPM Machines Incontinence Supplies Custom Wheelchairs Power Wheelchairs Manual Wheelchairs Nutritional Supplements Diabetic Test Supplies Walkers, Canes, Commodes Hospital Beds / Mattresses Other: Describe Below or attach list of products. ___________________________________________________ ___________________________________________________ 10. Does this Home Medical Device Retailer currently employ the person whose name appears on this application? 11. Will this person replace an Exemptee licensed by the California Department of Public Health? Name of Exemptee being replaced : ______________________________________________________________ 12. List business hours and days that the applicant will be working at this facility: ____________________________ 13. Enter other Exemptee license number(s) that applicant possesses: _______________________________ 14. If applicant is working at various locations explain how facility intends to provide coverage in applicant's absence: Yes Yes No No (Attach copy) Exemptee Number: ___________________________ ______________________________________________________________________________________________________________ (attach a separate sheet if necessary) 15. Certification of Employer Read carefully and sign below I hereby certify that the application completed on this form is being presented to the Food and Drug Branch with my knowledge and approval. Also, it is my understanding that a person certified by the Food and Drug Branch must be on the premises and actively supervising operations at all times when prescription devices are being dispensed. I 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 the foregoing application, including all supplementary statements. 16. Employer's original signature: (in blue ink) Title of person signing: Date: 17. License Fee Due (Fee is Non Refundable) Enter Each Fee Below: License fee (see page 3) Late Fee ($10 if over 30 days late) Total Payment Due $ $ $ Make Checks Payable to: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH See page 3 for mailing address CDPH 8695 (09/09) Fund Code 3018 Index 5624 PCA 76223 Receipt Source 125700 Agency Source 49 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com State of California--Health and Human Services Agency California Department of Public Health Food and Drug Branch Home Medical Device Retailer Exemptee License Application Instructions Please complete and/or amend this application as is most appropriate to your facility. Include the appropriate fee for each application as indicated in the fee schedule and make check payable to: CA DEPARTMENT OF PUBLIC HEALTH. The application cannot be processed without the appropriate fees, complete d
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