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Forms
By SkillsPlus International

Forms Provided To Support Your Application Process

This page will link you to a form to download as well as valuable links on the California Board of Pharmacy and Department of Health Services.

Forms

California Board of Pharmacy

Department of Public Health (Exemptee Application)

Request for finger print cards (out-of-state vendors)

Self Assessment form

Writing Procedures: Drug and Device Wholesalers and HMDR

References

Does my device require an HMDR Exemptee?

Contact us for a prompt reply!

©2010 SkillsPlus International Inc. 

Advancing the Competitive Edge

Does my device require an HMDR Exemptee?

Review this list. It may not be exhaustive. The list was supplied from the DHS web site. If your device is not on the list and DHS has told you that you need an Exemptee, check with the Department of Health Services for further clarification.

• Automatic External Defibrillators (AEDs) DM01 

• Blood Glucose Monitors and Supplies (mail order) DM06

• Blood Glucose Monitors and Supplies (non-mail order) DM05

• Breast Prostheses and Accessories PD01  

• Canes and Crutches M01

• Cochlear Implants PD02

• Commodes/Urinals/Bedpans DM02

• Continuous Passive Motion (CPM) Devices DM03

• Continuous Positive Airway Pressure (CPAP) Devices R01

• Contracture Treatment Devices: Dynamic Splint DM04

• Diabetic Shoes/Inserts S02  

• Enteral Nutrients, Equipment and Supplies PE01

• External Infusion Pumps and Supplies DM12

• Eye Prostheses PR02  

• Facial Prostheses PD03

• Gastric Suction Pumps DM07  

• Heat & Cold Applications DM08

• Hemodialysis Equipment and Supplies HD02

• High Frequency Chest Wall Oscillation (HFCWO) Devices R02

• Home Dialysis Equipment and Supplies HD01

• Hospital Beds-Electric DM09

• Hospital Beds-Manual DM10  

• Implanted Infusion Pumps and Supplies DM14

• Infrared Heating Pad Systems DM11

• Insulin Infusion Pumps and Supplies DM13

• Intermittent Positive Pressure Breathing (IPPB) Devices R04

• Intrapulmonary Percussive Ventilation Devices R05

• Invasive Mechanical Ventilation Devices R03  

• Limb Prostheses PR01

• Mechanical In-Exsufflation Devices R06  

• Nebulizer Equipment and Supplies R07

• Negative Pressure Wound Therapy Pumps and Supplies DM15

• Neuromuscular Electrical Stimulators (NMES) DM16

• Neurostimulators PD04  

• Ocular Prostheses PD05

• Orthoses: Custom Fabricated OR01

• Orthoses: Prefabricated (non-custom fabricated) OR02

• Orthoses: Off-The-Shelf OR03

• Osteogenesis Stimulators DM17

• Ostomy Supplies PD06

• Oxygen Equipment and Supplies R08  

• Parenteral Nutrients, Equipment and Supplies PE02

• Patient Lifts M02

• Pneumatic Compression Devices DM18

• Power Operated Vehicles (Scooters) M03

• Prosthetic Lenses: Conventional Contact Lenses PD12

• Prosthetic Lenses: Conventional Eyeglasses PD11

• Prosthetic Lenses: Prosthetic Cataract Lenses PD13  

• Respiratory Assist Devices R09  

• Respiratory Suction Pumps R10

• Seat Lift Mechanisms M04

• Somatic Prostheses PD07

• Speech Generating Devices DM19

• Support Surfaces: Pressure Reducing Beds/Mattresses/Overlays/Pads DM20

• Surgical Dressings S01  

• Tracheostomy Care Supplies R11

• Tracheostomy Supplies PD08

• Traction Equipment DM21

• Transcutaneous Electrical Nerve Stimulators (TENS) DM22  

• Ultraviolet Light Devices DM23

• Urological Supplies PD09  

• Ventilators Accessories/Supplies R12

• Voice Prosthetics PD10  

• Walkers M05

• Wheelchair Seating/Cushions M10

• Wheelchairs-Complex Rehabilitative Manual Wheelchairs M08

• Wheelchairs-Complex Rehabilitative Manual Wheelchairs Related Accessories M08a

• Wheelchairs-Complex Rehabilitative Power Wheelchairs M09

• Wheelchairs-Complex Rehabilitative Power Wheelchairs Related Accessories M09a

• Wheelchairs-Standard Manual M06

• Wheelchairs-Standard Manual Related Accessories M06a

• Wheelchairs-Standard Power M07

• Wheelchairs-Standard Power Related Accessories M07a