Multiple Sites (Fixed And/Or Mobile)

IAC MRI

Multiple Sites (fixed and/or mobile)

Supplemental Application

Application supplement to be completed by facilities
adding multiple sites to a current accreditation.

Sites must be added to the Online Accreditation portal (iaconlineaccreditation.org) in order to be processed.

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018

* The application process requires good faith participation, including full accuracy of documents submitted. Any facility determined to have falsified documents faces loss of accreditation, suspension from the accreditation process and referral to appropriate state and federal government agencies. Falsification includes deletion or fabrication of data. The IAC reserves the right to randomly audit applications for the purpose of detection of falsification.

Intersocietal Accreditation Commission

Affidavit of Change in Ownership or Operations

Instructions: Use this form to report changes in ownership or operations to IAC. A modification of accreditation status or transfer of ownership will not be final unless required fees are paid and this affidavit is signed by IAC. IAC may ask that you submit additional information and an opinion letter from your legal counsel to confirm the information provided in this affidavit.

The accredited facility (“Facility”) is:

Name:
Application #:
Address:
EIN (Federal Tax ID):
Division (check all that apply):
/ Vascular Testing
Echocardiography
Nuclear/PET
MRI
CT
Carotid Stenting
Dental CT
Vein Center
Cardiac Electrophysiology
Cardiovascular Catheterization
Does the Facility have multiple sites (fixed and/or mobile)? If so, list the addresses of each site here (use additional sheets, if necessary): / 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Provide information below for all the changes that apply:

Change of ownership
Name of new owner:
EIN of new owner:
Address of new owner:
Change of name
New name:
Change of address
New address:
Change in Medical Director
Name of current Medical Director:
Change in Technical Director
Name of current Technical Director:
Other:

Using Facility letterhead, please attach a detailed explanation of the situation in your own words. If other changes in personnel or equipment have taken place, describe those changes. If the Facility has multiple sites, explain how each site is or is not affected by the change. Please include dates, full legal names, addresses, whether there was a dissolution, merger, or other corporate change and any other information that you think would be helpful.

The effective date of the change is:

To the best of my knowledge and belief, I certify that at the time of this change, the Facility and, if applicable, its new owner:

Had a qualified Medical Director;
Had a qualified Technical Director;
Assumed and agreed to be bound by the terms of the IAC Accreditation Agreement; and
Was in compliance with all IAC Standards, policies and procedures.

On behalf of the Facility, I request that IAC approve the change and modify the Facility’s accreditation status or transfer of ownership accordingly. I represent and warrant that I have authority to execute this affidavit on behalf of the Facility. Under penalty of perjury, I certify that the above information is accurate, true, and complete.

By: ______

Name:

Title:

Date:

Reviewed & Approved by IAC:

By: ______

Name:

Title:

Date:

IAC Multiple Sites (Fixed and/or Mobile)
MRIFacilityResponse Sheet

Name of Institution (as listed in the Accreditation Agreement):

(This institution name will be tracked in the IAC database and will receive all IAC correspondence.)

Facility application/accreditation number:

Number of sites included with this application:

Prior to completing this application supplement, refer to the IAC MRIStandards for Multiple Sites (Fixed and/or Mobile). Multiple site refers to facility sites operated by the same corporation/entity and meeting the following criteria, without exception:

Multiple Sites (Fixed and/or Mobile)
In order to qualify as a multiple site facility, the following information as listed in the IAC Accreditation Policies and Procedures will apply.

Multiple sites refer to two or more fixed sites where testing/procedures are performed.

The accreditation will be “owned” only by the legal entity with the EIN listed on the Agreement.

Organizations performing mobile testing at multiple locations may apply on a single application if the sites meet all of the requirements published in the division Standards. Additional application information will be required and additional fees will apply.

For multiple site applications:

All correspondence will go through the address listed on the Accreditation Agreement.
Each site may be granted accreditation independently based on adherence to the Standards.
Certificates are provided to each site granted accreditation and each site is published on the IAC division website.
In general, the site with the highest testing volumes will be named as the main site. However, this may vary based upon the operational structure of the facility.

Multiple sites are not required to apply for identical testing areas. Each multiple site may apply only for the examinations that are performed at the site.

An accredited facility may add an additional site at any time during the period when accreditation is valid by completing the multiple site application supplement and submitting the required additional fees. If granted, all of the sites will expire at the time of the original accreditation decision.

Refer to the Standards for the Multiple Site (Fixed and/or Mobile) criteria.

Case Study Requirements

Applicant facilities must submit six total case studies for each MRI unit. Cases must represent each area of testing that is performed on the scanner (i.e., Cardiovascular MRI, Breast MRI, Body MRI [chest (non-cardiac), abdomen, pelvis, extremity], Musculoskeletal MRI, Neurological MRI, MRA).

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018

Body Accreditation
Case One: 1 upper abdomen (i.e., liver or kidney or pancreas)
Case Two: 1 soft tissue pelvis (i.e., ovaries or prostate)
Case Three: 1 mediastinum (non-cardiac)
Case Four: (choose any of the following): 1 soft tissue neck; or 1 brachial plexus; or
Case Five: choose any of the above, with pathology (these should be different studies than 1-3)

Case Six: 1 abnormal scan

Breast MRI Only
Submit six cases studies on CD or DVD with the viewer installed of all the sequences acquired used in the interpretation. All with pathology.

Cardiovascular MRI Accreditation

Case One: 1 complete gated cine cardiac examination in either a normal patient or in a patient with valvular heart disease

Case Two: 1 complete gated cine cardiac examination in a post myocardial-infarction patient

Case Three: 1 complete aortic study demonstrating all sections of either the thoracic or abdominal aorta in a patient with pathology

Case Four & Five: Any of the above with pathology (these should be different studies than cases 1-3)

Case Six: 1 abnormal scan

Musculoskeletal Accreditation
Case One:1 knee
Case Two: 1 shoulder (if shoulder exams are not performed choose one of the following):
1 wrist; or
1 ankle; or
1 foot; or
1 elbow

Case Three: (choose one of the following not represented in case two):
1 wrist; or
1 ankle; or
1 foot; or
1 elbow; or
1 TMJ
1 spine (cervical, lumbar, thoracic)
Other:
Case Four & Five: Any of the above with pathology(these should be different studies than cases 1-3)
Case Six: 1 abnormal scan

Neurological Accreditation
Case One: 1 abnormal brain (MS or tumor)
Case Two: 1 abnormal spine
Case Three: 1 spine with herniated disc
Case Four& Case Five: Any of the above with pathology (these should be different studies than cases 1-3)

Case Six: 1 abnormal scan

MRA Accreditation
Neurological MRA Only; Body MRA Only; or Both Neurological and Body MRA
Submit 6 cases total for the MRA testing area. If applying in both body and neurological MRA submit 3 neurological (extracranial and intracranial vessels) and 3 body MRA (non-cardiac) studies

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018

For complete case studies requirements, please visit intersocietal.org/mri/seeking/case_studies.htm.

List the name and addresses of all sites included in this application and complete the following pages for each location.

Site/location # / Site/location name / Site/location address

(Please complete one form below per location.)

Name of institution (as listed in the Accreditation Agreement):

(This institution name will be tracked in the IAC database and will receive all IAC correspondence.)

Site/Location Number (assign consecutive numbers to sites):
Name of Site/Location:
NPI Number:
Tax ID:
Medicare Enrollment Number:
Department:
Address:
City: State: Zip Code:
Located in:
Hospital
Physician office separate from hospital
Multispecialty clinic
Independent facility (e.g., IDTF)
Other (specify):
Type of Accreditation Applying for at this Site/Location (please check all that apply):
Body (pelvis, abdomen, chest (non-cardiac) and/or extremity)
Breast
Cardiovascular
Musculoskeletal
Neurological (brain and spine)
MRA (neuro and/or body)

Volume of Testing (specific to this site)

List the number of procedures performed at this site annually, by type of examination. List ALL procedures performed at this site, even if you are not applying for accreditation in all areas.

Clinical Area /

Annual Volume

Body
Pelvis
Abdomen
Chest
ST Neck
Other: ()
Breast

Cardiovascular

Heart

MRI
Other: ()

Musculoskeletal

Shoulder
Elbow
Wrist/Hand
Hip/Pelvis
Knee
Foot/Ankle
Long Bone
TMJ
MRA
Spine (cervical, lumbar, thoracic)
Other:()
Neurological
Brain
Cervical Spine
Thoracic Spine
Lumbar Spine
Other: ()
MRA
Body
Neurological

Are the following available to deal with medical emergencies at the above site/location?

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018

Oxygen/Airway: Yes No

Emergency Drugs: Yes No

Defibrillator: Yes No

CPR Certified Staff: Yes No

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018

If no to any of the above, please explain:

Note: You may copy this page for additional sites and/or locations

Is there one Medical Director (the same individual) for all of the sites/locations?

Yes No

If no, please explain:

Is there one Technical Director (the same individual) for all of the sites/locations?

Yes No

If no, please explain:

Are all staff members (technologists and physicians) that perform/interpret any magnetic resonance procedures at the above listed sites/locations included in the MRI application for accreditation (including staff forms)?If no, the facility’s online accreditation account (Manage Staff) must be updated to reflect all current staff members (medical and technical).

Yes No

If no, please explain:

Are all staff members involved in Quality Improvement (QI) and correlation procedures?

Yes No

If no, please explain:

Are all staff members involved in education programs, including in-house conferences?

Yes No

If no, please explain:

Do all of the sites/locations utilize similar protocols?

Yes No

If no, please explain:

Have you included on the Equipment and Instrumentation Table, within your application, all MRI equipment used at any of the above sites/locations?

Yes No

If no, please explain:

Attestation

I attest that the information provided about this site is accurate and meets the current IAC Standards and Guidelines for MRI Accreditation.

Name:

Title:

Date:

Signature: ______

IAC MRI Multiple Site Supplemental Application1

Reviewed 1/15/2018