Get Application For Ct Screening - Minnesota Department Of Health

Completing the Application For CT Screening is an essential step for facilities seeking to initiate or maintain a self-referral screening program. This guide provides a clear and structured approach to filling out the form accurately and efficiently online.

Follow the steps to successfully complete the application online.

1. Press the ‘Get Form’ button to access the application form online.
2. Select the appropriate type of application by checking one of the options provided: new CT screening application, revision to screening program, or renewal of screening program. Additionally, indicate which self-referral screening program(s) you are applying for, such as CT cardiac, CT colon, or CT lung.
3. Provide the facility name and mailing address of the applicant in the specified fields. Make sure to include accurate and complete information to avoid any delays in processing.
4. If the screening site name differs from the facility name, provide the name and address where the self-referral screening will be conducted.
5. Insert the name of the individual to be contacted regarding the application, along with their title and email address. This ensures that communication is direct and efficient.
6. Enter the contact person's phone number in the specified field to facilitate timely follow-up if needed.
7. Submit the application and items 5 through 18 electronically to the provided email address: health.ram@state.mn.us. Make sure all required items are completed before submission.
8. Complete sections 5 through 18, providing detailed responses for each question, including the purposes of the screening program, descriptions of the examination, facilities, and equipment, alternative methods, and quality assurance programs.
9. Indicate the qualifications of individuals performing and supervising the examinations, as well as those of the interpreting physicians, ensuring that all qualifications are documented accordingly.
10. Describe the procedures for informing individuals screened and their private practitioners, the retention of acquired images, and the frequency for screening patients.
11. Acknowledge that all statements and representations made in this application are binding upon the applicant by providing the name, title, phone number, and date of the administrator responsible for the application.

Complete your application for CT screening online today.