IAC DENTALCT MULTIPLE SITE
(Fixed and/or Mobile)

SUPPLEMENTAL APPLICATION

IAC Multiple Site (Fixed and/or Mobile) Requirements:

Prior to completing this application supplement, refer to the IAC Standards and Guidelines for Dental CT Accreditation for Multiple Sites (Fixed and/or Mobile). Multiple site refers to facility sites operated by the same corporation/entity and meeting the following criteria, without exception:

  1. Multiple Sites (Fixed and/or Mobile)
    In order to qualify as a multiple site facility, the following information as listed in the IAC Accreditation Policies and Procedures will apply.
  1. Multiple sites refer to two or more fixed sites where Dental CT examinations are performed.
  1. The accreditation will be “owned” only by the legal entity with the EIN listed on the IAC Accreditation Agreement.
  1. Practices performing mobile CT examinations at multiple locations may apply on a single application if the sites meet all of the requirements published in the Standards. Additional application information will be required and additional fees will apply.
  1. For multiple site applications:
  1. All correspondence will go through the address listed on the IAC Accreditation Agreement.
  2. Each site may be granted accreditation independently based on adherence to the Standards.
  3. Certificates are provided to each site granted accreditation and each accredited site is published on the IAC Dental CT website.
  4. One site must be listed in the Manage Sites section of the online accreditation account as the Primary Site.
  1. An accredited practice may add an additional site at any time during the period when accreditation is valid by completing the Multiple Site Application and submitting the required additional fees. Once granted, all additional sites will expire at the time of the original accreditation.

* The application process requires good faith participation, including full accuracy of documents submitted. Any practice determined to have falsified documents faces loss of accreditation, suspension from the accreditation process and referral to appropriate state and federal government agencies. Falsification includes deletion or fabrication of data. The IAC reserves the right to randomly audit applications for the purpose of detection of falsification

IAC Dental CT Multiple Site Supplemental Application

(Please complete one form below per site.)

Name of Practice (as listed in the IAC Accreditation Agreement):

Application Number:
Site Number (assign consecutive numbers to sites):
Name of Site:
Address:
City: State: Zip Code:
Located in:
Hospital Dental or Medical office Mobile only
Other (specify):

CT Unit Information (for the additional site listed above):

Manufacturer:

Model:

Serial Number:

Slice Capacity: (Note: If this is a cone beam CT unit, enter “cone beam”)

Date of Installation:

Year of Manufacture:

Is there one Dental or Medical Director (the same individual) for all of the sites?

Yes No

If no, please explain:

Are all staff members (dental hygienists/assistants, dentists, physicians) that perform/interpret Dental CT examinations at the above listed site included in theManage Staff section of the Online Accreditation Account?

Yes No

If no, please explain:

Do all of the sites utilize similar CT imaging protocols?

Yes No

If no, please explain:

Have you included all CT units (for each site/location) in the Manage Equipment section of the online accreditation account?

Yes No

If no, please explain:

Attestation

I attest that the information provided about this site is accurate and meets the current IAC Standards and Guidelines for Dental CT Accreditation.

Name:

Title:

Date:

Signature: ______

IAC Dental CT Multiple Site Checklist

Several items must be completed in the Online Accreditation Account and documents must be submitted when adding additional sites that are included in the checklist below:

Complete the following items in the facilities Online Accreditation Account:

Enter the additional site(s) in the Manage Sites section

Enter the additional dental CT unit(s) information in the Manage Equipment section

Enter all additional dental/medical staff members and technical staff members in the Manage Staff section (if appropriate)

Submit the following documentation via a traceable carrier such as UPS or FedEx:

A Multiple Site Supplemental Application form

A formal letter of notification from the Medical or Technical Director that the facility has added a dental CT site

The acceptance test results of radiation dose assessment and image quality assessments performed by a medical physicist/qualified expert (that includes the QC phantom images that can be in a .pdf or .jpeg format)

A post installation shielding verification survey performed by a medical physicist/qualified expert

5 days of routine operator quality control (QC) test results that include the QC log sheet/report that records the QC measurements and corresponding phantom images that display the QC measurements (the QC phantom images can be in a .pdf or .jpeg format)

A total of 6 case studies per CT unit that are representative of all accredited testing areas. Each case study must contain all images on a CD, DVD, or memory stick (flash drive) in a DICOM format with the DICOM viewer installed, the final report, and a Dental CT Scan Parameter Form. View theCase Studies Requirements for guidance related to the types of CT examinations to be submitted.

Multiple site fee: $1,325per site for sites 2-3; $1,085per site for sites 4-10 (20% discount); $875per site for each site over 10)

Submit requested documentation to:

IAC Dental CT

6021 University Boulevard, Suite 500

Ellicott City, MD 21043

Dental CT Multiple Site (Fixed and/or Mobile) Supplemental Application 1

Reviewed 1/15/2018