Request for Name Address Change CNA HHA Certificate
This form allows certified nursing assistants, home health aides, and certified hemodialysis technicians to request name or address changes or obtain duplicate certificates. It includes detailed instructions for completing the application correctly. Prompt submission ensures your records remain current and accurate.
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How do I fill this out?
To fill out this form, start by clearly identifying your request type at the top of the form. Ensure all sections that apply are completed with accurate information, especially those with an asterisk. Finally, review your entries for completeness before submitting the application.
How to fill out the Request for Name Address Change CNA HHA Certificate?
1
Identify the request type at the top of the form.
2
Complete all applicable sections with accurate information.
3
Provide required legal documentation for name changes.
4
Sign and date the form at the bottom.
5
Submit the completed form to the appropriate department.
Who needs the Request for Name Address Change CNA HHA Certificate?
1
Certified nursing assistants needing to change their contact details.
2
Home health aides requiring a new address for communication.
3
Individuals who have legally changed their name and need to update records.
4
Certified hemodialysis technicians looking for duplicate certificates.
5
Any healthcare professional seeking to maintain accurate certification records.
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Click on the sections you want to edit and input your changes.
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Review all changes to ensure accuracy.
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Download the edited file for submission.
What are the instructions for submitting this form?
To submit this form, you can mail it to the California Department of Public Health at P.O. Box 997416, Sacramento, CA 95899-7416. Alternatively, you can fax your application to (916) 552-8785. If needed, you can also reach out via email at cna@cdph.ca.gov for inquiries related to your submission.
What are the important dates for this form in 2024 and 2025?
Important dates for this form have not been specified, however, it’s essential to submit your requests promptly. Changes may be processed more quickly before major holidays or peak filing seasons. Keep an eye on announcements from the California Department of Public Health for any updates.
What is the purpose of this form?
The purpose of this form is to allow certified nursing assistants, home health aides, and certified hemodialysis technicians to request changes to their personal information on official records. Maintaining updated information is crucial for compliance with state regulations and ensuring proper communications. Additionally, it serves to provide a means to obtain duplicate certificates if they are lost or damaged.
Tell me about this form and its components and fields line-by-line.
- 1. LAST NAME: Your last name as recorded in certification records.
- 2. FIRST NAME: Your first name as recorded in certification records.
- 3. DATE OF BIRTH: Your birthdate to verify identity.
- 4. CERTIFICATE NUMBER: The unique number assigned to your certificate.
- 5. SOCIAL SECURITY NUMBER: Required for identification and processing purposes.
- 6. EMAIL ADDRESS: Your email for any communications from the department.
- 7. PUBLIC ADDRESS: Your current address that is subject to public records.
- 8. CONFIDENTIAL ADDRESS: Optional field for individuals requesting confidentiality of their address.
- 9. PREVIOUS ADDRESS: Your address prior to the change being requested.
What happens if I fail to submit this form?
Failure to submit this form correctly may lead to delays in processing your request and maintaining your certification. It is important to ensure all required fields are filled accurately to avoid unnecessary complications. Incomplete or inaccurate submissions may be returned for correction, prolonging the update process.
- Incomplete Information: Any missing required fields can cause a return of your application.
- Signature Issues: Failure to sign the form will result in the denial of your application.
- Outdated Contact Details: If your details are not updated, you may miss critical communications.
How do I know when to use this form?
- 1. Address Change: To update your address on record.
- 2. Name Change: To request updates on your name due to legal changes.
- 3. Duplicate Certificate Request: For obtaining a new copy of your certification.
Frequently Asked Questions
How do I fill out the request form?
Begin by selecting the type of request you are making, then complete all required fields with accurate information.
Can I submit this form online?
Currently, the form must be printed and submitted via mail or fax. Online submission options are not available.
What documentation do I need for name changes?
You must include a photocopy of legal documents such as marriage certificates or court documents that verify your name change.
How can I get a duplicate certificate?
To request a duplicate certificate, select the 'Duplicate Request' option and ensure you've filled in all required sections.
What if I forget to sign the form?
Your application will be returned if it is not signed. Be sure to check the signature section before submission.
Is there a fee associated with this request?
There are no fees for requesting name or address changes; however, fees may apply for duplicate requests.
What should I do if my address is confidential?
If your address is confidential, fill in the 'CONFIDENTIAL ADDRESS' section to ensure your details are protected.
Can I change my email address on the form?
Yes, you can update your email address; just ensure that the information is entered correctly.
Where do I send the completed form?
Submit the completed form to the address specified at the top: California Department of Public Health, Licensing and Certification Program.
What is the processing time for my application?
Processing times may vary; you should allow several weeks for the form to be processed once submitted.
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