To submit this form, send your completed application along with the required documents to the California Department of Public Health at the designated mailing address. For USPS First-Class Mail, send it to MS 7610, P.O. Box 997414, Sacramento, CA 95899-7414. For Express Mail, the address is 1500 Capitol Ave., Suite 520, Bldg. 172, Sacramento, CA 95814-5006. Always ensure you include the non-refundable fee of $127 and track your submission to confirm receipt.

While specific dates for 2024 and 2025 regarding this form have not been established, it’s essential to keep updated with submission deadlines to maintain your certification status. Regularly check the CDPH website for any changes in requirements or deadlines for application submissions.

The purpose of this form is to facilitate the process for radiologists and radiation oncologists to obtain the necessary certification to practice in California. By completing this application, individuals demonstrate their qualifications and commitment to meeting state regulations governing radiology practices. This certification is not only a legal requirement but also ensures that standard practices are upheld in the field, protecting patients and practitioners alike.

• 1. Last Name: Applicant's last name for identification.
• 2. First Name: Applicant's first name for identification.
• 3. Date of Birth: Applicant's date of birth.
• 4. SSN or ITIN: Social Security Number or Individual Taxpayer Identification Number.
• 5. Mailing Address: Physical or mailing address for correspondence.
• 6. City: City of residence.
• 7. State: State of residence.
• 8. Middle Name: Applicant's middle name.
• 9. Phone Number: Contact phone number.
• 10. E-mail Address: Contact email address.
• 11. Zip Code: Postal code for the mailing address.

If you fail to submit this form, you will be unable to obtain the Radiology Supervisor and Operator Certificate necessary for your practice. This could result in legal repercussions as operating without certification is against California law. It's essential to fulfill all submission requirements to avoid delays in your certification process.

• Ineligibility to Practice: Practicing without certification can lead to legal issues.
• Delays in Certification: Incomplete applications can stall the processing of your certification.
• Loss of Professional Opportunities: Not being certified can limit job prospects in the radiology field.

• 1. Applying for Initial Certification: Use this application if you are seeking initial certification as a radiology supervisor or operator.
• 2. Responding to Certification Renewal: Complete this form when renewing your certification to maintain compliance.
• 3. Changing Certification Status: Utilize this application if changing your specialty or certification status.