Get Cna Imaging Supplemental Application Fillable Form

Filling out the Cna Imaging Supplemental Application Fillable Form online is a straightforward process. This guide provides detailed instructions to help you navigate each section of the form efficiently, ensuring that all necessary information is accurately provided.

Follow the steps to complete the form seamlessly.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by filling in the name of the applicant in the designated field. Ensure that the name is spelled correctly and reflects the official name of the entity or individual applying.
3. Next, complete the risk management contact section. Provide a relevant contact person's name and their email address to ensure proper communication regarding the application.
4. In the type of services section, identify all applicable services by entering the annual gross receipts for both therapeutic and diagnostic categories. This may include a variety of imaging services such as MRI, CT, or X-ray.
5. Indicate who conducts the first read of the diagnostic/imaging test results by selecting either the applicant’s employed or contracted radiologist or the patient’s personal physician.
6. For the responsibility of providing test results to the patient, repeat the previous selection process to clarify who delivers this information.
7. Check all applicable options regarding the applicant's invoice/billing practices. Ensure you indicate the percentage of revenues for each listed procedure relevant to your operations.
8. Document whether the diagnostic/imaging equipment is maintained by an outside party or by the applicant, ticking the appropriate box.
9. If the applicant is injecting contrast media, provide the percentages of use for ionic, non-ionic, and low osmolar media. Confirm whether protocols exist for their use and detail if a physician is present during the procedure.
10. Complete the screening mammography section by answering questions regarding the use of computer-aided systems, second radiologist reviews, and digital mammography capabilities.
11. Provide any required documentation for accreditations, licensure, and certifications held by the organization. Note any FDA warning letters and confirm FDA certification for mammography services if applicable.
12. Address the quality improvement/peer review section, indicating whether an external peer review program exists and detailing the facility's peer review process if needed.
13. In the staffing portion, list qualifications for key personnel involved in invasive procedures, including any specialized certifications held by technicians/technologists.
14. Indicate whether the applicant transports any diagnostic/radiology equipment and specify the percentage of services represented by mobile radiology if applicable.
15. Confirm the availability of emergency equipment and medications, describe the staff's CPR training, and the existence of mock codes.
16. If applicable, indicate if the applicant provides teleradiology services and confirm the licensing and residency of the reading physician.
17. Finally, indicate whether a digital PAC radiology system is implemented.
18. Complete the authorization section by providing your signature, the date, your printed name, agency name and address, along with the contact details of the person submitting the application.
19. Once all fields are filled, save your changes. You can then download, print, or share the completed form as needed.

Start filling out your Cna Imaging Supplemental Application online today to ensure timely processing of your submission.