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Printable Form 8379 Orange California: What You Should Know

Form. CDP 284 (PDF). This form certifies that the customer pays a minimum of 100 an ounce to have their urine and blood analyzed. (If the customer pays more than 140 per ounce and has an insurance policy that provides this coverage, the amount paid will be added to the customer's health care costs for the entire amount paid). Note: When using these certifications in an application submission, they are optional. For information, contact the Certified Hemodialysis Technician directly. See page 7 of theseĀ certificates.Ā  Certified Hemodialysis Technician Initial Application. (PDF). CDP 284. This form is used if a customer pays a minimum of 100 an ounce to have their urine and blood analyzed. (If the customer pays more than 140 per ounce, plus the cost of the evaluation and testing, and an insurance policy that provides this coverage, the amount paid will be added to the customer's health care costs for the entire amount paid). This form can also be used for employees, such as employees who use this service on an hourly basis or for a customer who pays out of an account in which the customer is the insured, or for a business that pays the patient. If the customer pays 500 an ounce or more, please obtain a statement signed by a qualified medical professional. This statement is required if the patient is older than 16 years of age and is under medical supervision and is being treated by a certified medical professional. If the patient is not under medical supervision and is not being treated by a certified medical professional, the statement must be notarized. Also, if the medical professional providing care to the patient is a licensed physician, dentist, optometrist, podiatrist, or other medical professional duly licensed in this state and conducting the examination or testing, then the statement for the examination or test may be also a physician's certification. The Certified Hemodialysis Technician Annual Training Report. (PDF) CDP 464. This form is provided for the customers' personal records and is only submitted to the IRS for IRS purposes if the customer is applying for an allocation. (If the customer is applying to the IRS for payment for the allocation of his/her allocation, including a request for a refund, then the customer is submitting these records as required by the statute.) See page 1 of the Certification for Allocation. Certified Hemodialysis Technician Supplemental Application. (PDF) CDP 628. This form is provided to the customer.

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