Get Mammography Machine Application For Certificate Of Authorization - Health Nv

The Mammography Machine Application for Certificate of Authorization in Nevada is an essential document for facilities operating mammography machines. This guide provides step-by-step instructions on how to complete the application accurately and efficiently online.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application and open it in your chosen editing tool.
2. Begin by entering the facility name in the designated field where the certificate will be issued. Provide the telephone number, email address, fax number, and mailing address, including city, state, and zip code.
3. If the physical address differs from the mailing address, fill in the physical address section with the same details as above.
4. Indicate the name and title of the individual completing the form. Include their telephone number and email address.
5. Enter the name of the supervising physician, along with the location of the mammography practice, selecting from the provided options (private office, hospital, mobile unit, etc.).
6. Specify the number of mammography machines in use and the average number of mammograms performed monthly at that location. Additionally, provide the proportion of total mammograms conducted for clinical indications.
7. Answer whether non-breast imaging studies are performed at the facility and provide relevant details about any organizational authorizations needed to complete the form.
8. List all personnel involved, including radiologists and mammography technologists, along with their relevant certifications and years of experience in mammography.
9. For each mammography machine, provide specifications such as manufacturer, date of manufacture, generator serial number, and focus receptor distance. Include supporting documents like a phantom image and the physicist's post-installation report.
10. Complete the image recording system section by indicating the type and brand of film/screen system used, processor details, and whether there is a change from the previous system.
11. Fill in the quality assurance program section, detailing the patient history taken as part of the mammographic study and the mechanisms in place for follow-ups on findings.
12. Review all information provided to ensure accuracy. The individual completing the form must attest to the correctness by signing and dating the document.
13. Finalize your application by paying the required fee, which is $551.00 per machine, and prepare to submit the completed document.
14. After ensuring all sections are filled, save the changes made. You may then download, print, or share the form as needed.

Complete your Mammography Machine Application online today to ensure your facility remains compliant and authorized.