Home Medical Device Retailer License Application {CDPH 8679}

CDPH 8679 - HOME MEDICAL DEVICE RETAILER LICENSE APPLICATION. This form is used by individuals seeking to obtain or renew a license to distribute or dispense prescription medical devices at a Home Medical Device Retailer (HMDR) facility in California. It requires personal information, details about the HMDR facility, and proof of qualifications, including education and work experience. The form must be signed by both the applicant and the employer, and it includes a section for the employer to verify the employment and detail the products handled. A fee is required, and the application must be submitted to the California Department of Public Health. 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. www.FormsWorkflow.com