IAC MRI MULTIPLE SITE
(Fixed and/or Mobile)
SUPPLEMENTAL APPLICATION
Application supplement to be completed by
facilities adding sites (fixed and/or mobile)
to a current MRI accreditation.
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.
1.
The accredited facility (“Facility”) is:
Name:
Application #:
Address:
EIN (Federal Tax ID):
Division (check all that
apply):
Does the Facility have
multiple sites (fixed
and/or mobile)? If so,
list the addresses of each
site here (use additional
sheets, if necessary):
Vascular Testing
Echocardiography
Nuclear/PET
MRI
CT
Carotid Stenting
Dental CT
Vein Center
Cardiac Electrophysiology
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
2
* 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.
2.
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:
3.
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.
4.
The effective date of the change is:
5.
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:
A.
B.
C.
D.
6.
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:
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
3
* 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.
IAC Multiple Sites (Fixed and/or Mobile)
MRI Facility Response 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 MRI Standards 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:
1.
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.
A. Multiple sites refer to two or more fixed sites where testing/procedures are performed.
B. The accreditation will be “owned” only by the legal entity with the EIN listed on the Agreement.
C. 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.
D. For multiple site applications:
i. All correspondence will go through the address listed on the Accreditation Agreement.
ii. Each site may be granted accreditation independently based on adherence to the Standards.
iii. Certificates are provided to each site granted accreditation and each site is published on the IAC
division website.
iv. 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.
E. 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.
F.
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.
G. Refer to the Standards for the Multiple Site (Fixed and/or Mobile) criteria.
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
4
* 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.
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).

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
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

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
For complete case studies requirements, please visit intersocietal.org/mri/seeking/case_studies.htm.
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
5
* 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.
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
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
Site/location address
6
* 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.
(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
Body
Pelvis
Abdomen
Chest
ST Neck
Other: (
)
Annual Volume
Breast
Cardiovascular
Heart
MRI
Other: (
)
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
7
* 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.
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?
Oxygen/Airway:
Emergency Drugs:
Yes
Yes
No
No
Defibrillator:
CPR Certified Staff:
Yes
Yes
No
No
If no to any of the above, please explain:
Note: You may copy this page for additional sites and/or locations

Attach, behind this page, an Organizational Chart that includes the Medical Director, Technical Director and all physicians and
technologists that perform or interpret any MRI procedures at any of the sites or locations included in your application for
accreditation. The chart should indicate at which of these sites or locations each staff member performs or interprets any CT
procedures.
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
8
* 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.
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:
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
9
* 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.
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: __________________________________________
Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 6/2015
10
* 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.