Get Application For Self Referral Screening Utilizing Radiation Generating - Odh Ohio

Filling out the Application for Self Referral Screening Utilizing Radiation Generating Equipment is an important task that requires attention to detail. This guide provides a comprehensive step-by-step approach to ensure a smooth completion of the form online, catering to all users regardless of their prior experience.

Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your facility identification details, including the name, Ohio radiation source handler registration number, and, if applicable, the health care facility license number. Also, input the address where the screening will be conducted.
3. Next, specify the proposed screening type by providing a description of the disease or condition you aim to examine.
4. In the population to be examined section, indicate the age, sex, and physical condition of the individuals who will be screened. Fill out any additional details as necessary.
5. Provide a thorough evaluation of known alternative screening methods that do not involve ionizing radiation. Clearly indicate why these methods are not being preferred over an x-ray examination.
6. Outline your x-ray quality assurance program, detailing specific aspects related to image quality control.
7. Describe the procedure you will use to notify the individuals screened and their physicians of the results of the screening procedure, as well as any recommendations provided by the screening facility or interpreting physicians.
8. Detail the retention and disposition of the radiographs, accompanying reports, and any other records pertaining to the screening procedure.
9. Input the name and qualifications of the physician proposing the screening program, including their Ohio medical license number and expiration date. Ensure that the physician's attestation is filled out by signing and dating where indicated.
10. Finally, provide the name and title of the person submitting the application, along with their contact telephone number and date. Review the completed application for accuracy.
11. Once all fields are filled, save changes to your application. You can then download, print, or share the completed form as needed.

Complete your application online today and ensure timely processing of your request.