Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to access the application form and open it in your online document editor.
2. Begin with the Facility Information section by entering the facility name, address, city, state, zip code, and contact information, including phone and fax numbers.
3. Provide the names and contact details for the supervising physician and include their license number and email address.
4. Indicate the type of facility in the appropriate checkboxes, and include details related to accreditation, such as the number of stationary and mobile units, along with ACR accreditation issue and expiration dates.
5. In the Action Requested section, select either Initial Certificate, Certificate Renewal, Change of Ownership, Change in Supervising Physician, or Change in Name. Ensure you include all required documentation for your selected action.
6. Complete the Staff Information section by entering the license number and category for the radiology technologist and the medical physicist.
7. Fill out the Ownership of Facility/Agency section by specifying the type of ownership and providing the names, addresses, and contact details for the owners.
8. Provide detailed information about all officers or owners with greater than 25% interest, including their names, titles, addresses, and percentage of ownership.
9. Read and execute the Certification of Understanding section, including logging your name, title, signature, and date to validate your application.
10. Lastly, ensure that all required documents are gathered following the checklist provided at the end of the form. Save your changes and download, print, or share the form as needed.

Complete your UT DoH Request For Agency Action/Certification Application - Mammography online today.