California > Statewide > Department Of Health And Human Services > Food And Drug
Home Medical Device Retailer License Application DHS 8679 - California
| Home Medical Device Retailer License Application 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 HOME MEDICAL DEVICE RETAILER LICENSE APPLICATION PLEASE COMPLETE THIS FORM FULLY--INCOMPLETE APPLICATIONS WILL BE RETURNED See page 2 for instructions NEW APPLICANT 1. Legal Name of Firm 2. DBA (List additional DBA's on separate sheet if necessary.) 3. Facility Address (number, street) 4. Facility Address (continued) 5. City State ZIP Code RELOCATION OWNERSHIP CHANGE OWNERSHIP AND LOCATION CHANGE RENEWAL 9. Facility Operator (name and title) 10. Facility Telephone Number 11. Facility FAX Number ( ( ) ) ( ) 12. 24-Hour Emergency Telephone Number 13. E-mail Address 14. Correspondent (name and title) 15. Correspondent Telephone Number 16. Correspondent FAX Number ( 6. Mailing Address (if different or P.O. Box number) 7. Mailing Address (continued) 8. City 19. Type of Ownership State ZIP Code ) ( ) 17. Country (if other than United States) 18. Website (URL) Individual/Sole Proprietorship 20. Corporate Name (if applicable) 21. Owners' or Officers' Names and Titles Partnership Corporation/Limited Liability Company State of Incorporation Other:_____________________ (attach copy of Partnership Agreement or Articles of Incorporation) Owners' or Officers' Names and Title s (Attach a separate list if needed). 22. Type of Application New HMDR (never licensed) New HMDR (additional location) New HMDR (address change) ____________________________ (previous HMDR license number) (previous HMDR license number) New HMDR (ownership change) __________________________ Renewal of an existing HMDR ____________________________ (HMDR license number) 23. Type of Business to be Conducted at this Location: HMDR Warehouse Only (storage) ________________________ (retail facility HMDR license number) Retail Sales/Distribution Business days and hours:_____________________ Warehouse Only Business license Number:____________________ (attach copy of business license) Seller's Permit Number:______________________ (attach copy of Seller's Permit) Federal Employee Identification Number (FEIN):____________________ (attach copy of FEIN) 24. The applicant retailer will be selling the following products: (check all that apply) * Asterisk indicates legend device - must have Pharmacist-in-charge (PIC) or a Licensed Exemptee on premises. ** Asterisks indicate product may be a legend device. 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 Air pressure Mattresses* Other--describe below or attach list of products ______________________________________ 25. If the HMDR facility will be selling/renting legend devices, respiratory equipment, or medical oxygen: Yes No (If Yes, attach a copy of PIC card) a. Will there be a pharmacist in charge (PIC) of operations at this location? b. Will there be an HMDR exemptee in charge of operations at this location? Yes No (If Yes, attach a copy of exemptee license) Name: ________________________________________________________ Exemptee License Number: ________________________________ Name: ________________________________________________________ Exemptee License Number: ________________________________ 26. Do you have a Medi-Cal or MediCare Provider number? (If currently applying for one, please check the Pending box) Medi-Cal Provider? Yes No Pending Yes No Pending Medicare Provider? 27. Payment Codes (Check only one code--see page 2 for schedule.) MAKE CHECKS PAYABLE TO: See page 2 for mailing address. Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says: (1) he/she is the applicant, or one of the owners or managers of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant's or applicants' business to be conducted under the license(s) for which this application is made; (4) all supplemental statements are true and accurate. 28. Signature of Applicant (original signature) License Number Expiration Date Printed name Date Received Title Payment Type Date Amount California Department of Public Health A--$850 B--$850 C--$425 (Fee is Non-Refundable) CA DEPARTMENT OF PUBLIC HEALTH PLEASE DO NOT WRITE IN GRAY AREA ABOVE THIS LINE. FOR STATE USE ONLY Fund 3018 Index 3018 Index 5624 CDPH 8679 (6/09) PCA 76212 Receipt Source 125700 Agency Source 49 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Home Medical Device Retailer License Application Instructions A separate application is required for each place of business. 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 payable to: CA DEPARTMENT OF PUBLIC HEALTH. This fee must accompany this application. Without the fee the application cannot be processed. Unsigned or incomplete applications cannot be processed. The following are further instructions on how to complete this application: Do not leave any sections blank. New Applicant / Renewal Applicant: Place an (X) in the box next to New Applicant if your firm has not previously applied for a Home Medical Device Retailer License at this location while under the current ownership. Place an (X) in the box next to Renewal Applicant if your firm has already obtained a Home Medical Device Retailer License for this location, and you are renewing that license. If your firm has changed location, ownership, or both, place an (X) in the box adjacent to the appropriate response. Check one box only. 1. 2. 3.5. 6.8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Legal Name of Firm: Enter full name of business, corporation, company, or organization applying for licensure. DBA: Enter any other name(s) your company is doing business as. Facility Address: Enter the number, street, city, state, and zip code for this facility location. Mailing Address: Enter the full mailing address if different from the facility address. Facility Op
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