IAC CT

Multiple Sites (fixed and/or mobile)

Supplemental Application

Application supplement to be completed by facilities
adding multiple sites to a current accreditation.

Sites must be added to the Online Accreditation portal (iaconlineaccreditation.org) in order to be processed.

IAC CT Multiple Site Supplemental Application1

Reviewed 1/15/2018

* The application process requires good faith participation, including full accuracy of documents submitted. Any facility 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.

Intersocietal Accreditation Commission

Affidavit of Change in Ownership or Operations

Instructions: Use this form to report changes in ownership or operations to IAC. A modification of accreditation status or transfer of ownership will not be final unless required fees are paid and this affidavit is signed by IAC. IAC may ask that you submit additional information and an opinion letter from your legal counsel to confirm the information provided in this affidavit.

  1. The accredited facility (“Facility”) is:

Name:
Application #:
Address:
EIN (Federal Tax ID):
Division (check all that apply):
/ Vascular Testing Vein Center
Echocardiography Nuclear/PET
CT Dental CT
Carotid Stenting MRI
Cardiac Electrophysiology Cardiovascular Catheterization
Does the Facility have multiple sites (fixed and/or mobile)? If so, list the addresses of each site here (use additional sheets, if necessary): / 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
  1. Provide information below for all the changes that apply:

Change of ownership
Name of new owner:
EIN of new owner:
Address of new owner:
Change of name
New name:
Change of address
New address:
Change in Medical Director
Name of current Medical Director:
Change in Technical Director
Name of current Technical Director:
Other:
  1. Using Facility letterhead, please attach a detailed explanation of the situation in your own words. If other changes in personnel or equipment have taken place, describe those changes. If the Facility has multiple sites, explain how each site is or is not affected by the change. Please include dates, full legal names, addresses, whether there was a dissolution, merger, or other corporate change and any other information that you think would be helpful.
  1. The effective date of the change is:
  1. To the best of my knowledge and belief, I certify that at the time of this change, the Facility and, if applicable, its new owner:
  1. Had a qualified Medical Director;
  2. Had a qualified Technical Director;
  3. Assumed and agreed to be bound by the terms of the IAC Accreditation Agreement; and
  4. Was in compliance with all IAC Standards, policies and procedures.
  1. On behalf of the Facility, I request that IAC approve the change and modify the Facility’s accreditation status or transfer of ownership accordingly. I represent and warrant that I have authority to execute this affidavit on behalf of the Facility. Under penalty of perjury, I certify that the above information is accurate, true, and complete.

By: ______

Name:

Title:

Date:

Reviewed & Approved by IAC:

By: ______

Name:

Title:

Date:

IAC Multiple Site (Fixed and/or Mobile) Requirements

Prior to completing this application supplement, refer to the IAC CT Standards and Guidelines 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 testing/procedures are performed.
  1. The accreditation will be “owned” only by the legal entity with the EIN listed on the Agreement.
  1. Organizations performing mobile testing at multiple locations may apply on a single application if the sites meet all of the requirements published in the division 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 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 site is published on the IAC division website.
  4. In general, the site with the highest testing volumes will be named as the main site. However, this may vary based upon the operational structure of the facility.
  1. Multiple sites are not required to apply for identical testing areas. Each multiple site may apply only for the examinations that are performed at the site.
  1. An accredited facility may add an additional site at any time during the period when accreditation is valid by completing the multiple site application supplement and submitting the required additional fees. If granted, all of the sites will expire at the time of the original accreditation decision.

Additional Site Information

Name of facility (as listed in the Accreditation Agreement):
(This facility name will be tracked in the IAC database and will receive all IAC correspondence.)
Name of Additional Site:
Additional Site Number (assign consecutive numbers to sites):
Additional Site Address:
City: State: Zip Code:
Additional Site Located in:
Hospital Physician office
Freestanding imaging center Mobile only
Other (specify):
Specific Testing Area(s) for this Additional Site (check all that apply):
Coronary Calcium Scoring
Coronary CTA
Neurological CT
Does the testing area of Neurological CT include Acute Stroke? Yes No
Body CT
Does the testing area of Body CT include Low Dose CT Lung Cancer Screening? Yes No
Maxillofacial CT OR Sinus CT Only
Vascular CTA
CT unit information for the additional site:
Ensure that the information for the CT unit for the additional site is listed in the Manage Equipment section of the Online Accreditation Account.
Manufacturer:
Model:
Serial Number:
Slice Capacity (for a Helical CT unit): OR Check the following box if this is a Cone beam CT unit:
Date of installation:
Year of manufacture:

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

Yes No

If no, please explain:

Is there one Technical Director (the same individual) for all of the sites?

Yes No

If no, please explain:

Are all staff members that perform or interpret the CT examinations at the above listed site included in the Manage Staff section of the Online Accreditation Account?

Yes No

If no, please explain:

Do all of the sites utilize similar imaging protocols?

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 CT Accreditation.

Name:

Title:

Date:

Signature: ______

IAC 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 CT unit(s) information in the Manage Equipment section

Enter all additional 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

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

Documentation of medical physicist/qualified expert’s report of radiation dose assessment and image
quality assessment (that includes the QC phantom images that can be in a .pdf or .jpeg format)

A post installation radiation shielding verification survey performed by the medical
physicist/qualified expert.

5 days of routine operator quality control (QC) test results performed after the CT unit was installed
that includes the QC log sheet/report 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 CT Scan Parameter Form. View the Case Studies
Requirements for guidance related to the types of CT examinations to be submitted.

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

Submit requested documentation to:

IAC CT

6021 University Boulevard, Suite 500

Ellicott City, MD 21043

IAC CT Multiple Site Supplemental Application1

Reviewed 1/15/2018

* The application process requires good faith participation, including full accuracy of documents submitted. Any facility 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.