IAC CT MULTIPLE SITE
(Fixed and/or Mobile)
SUPPLEMENTAL APPLICATION
Application supplement to be completed by
facilities adding sites (fixed and/or mobile)
to a current CT 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.
2.
Provide information below for all the changes that apply:
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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
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:
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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 Site (Fixed and/or Mobile)
CT 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 CT Standards and Guidelines 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.
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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* 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 CT scanner. Cases must represent each area of testing that is
performed on the scanner (i.e., Coronary Calcium Scoring CT, Coronary CTA, Neurological [Brain, Spine, Acute Stroke], Sinus
and Temporal Bone CT, Body CT [Chest (non-coronary), Low Dose CT Lung Cancer Screening, Abdomen, Pelvis, Extremity],
Vascular CTA [Chest (non-coronary), Abdomen, Pelvis, Peripheral/Extremity]).

o
o
o
o
o
o

Case One: mildly elevated calcium score
Case Two: severely elevated calcium score
Case Three: valvular/annular calcification
Case Four: extra coronary pathology
Case Five: demonstrating other pathology
Case Six: demonstrating other pathology
LOW DOSE CT (LDCT) LUNG CANCER SCREENING ONLY
o
Case One: LDCT – pulmonary nodule(s)
o
Case Two: LDCT - tumor
o
Case Three: LDCT - metastasis
o
Case Four: LDCT emphysema
o
Case Five: LDCT other pathology
o
Case Six: LDCT other pathology
Coronary CTA
o
o
o
o
o
o

BODY AND LOW DOSE CT (LDCT) LUNG CANCER
SCREENING
o
Case One: LDCT chest - tumor
o
Case Two: LDCT chest - pulmonary nodule
o
Case Three: chest - demonstrating pathology
o
Case Four: abdomen - demonstrating pathology
o
Case Five: pelvis - demonstrating pathology
o
Case Six: extremity - demonstrating pathology
Coronary Calcium Scoring CT
Case One: complete gated cine cardiac examination in a
normal patient
Case Two: cardiac examination in a patient with nonobstructive CAD
Case Three: cardiac examination in a patient with
obstructive CAD
Case Four: complete gated cine cardiac examination in
a patient with LV dysfunction secondary to myocardial
infarction
Case Five: cardiac examination in a patient with prior
coronary bypass graft
Case Six: abnormal scan

SINUS CT ONLY
o
Case One: demonstrating tumor
o
Case Two: chronic sinusitis
o
Case Three: demonstrating a deviated nasal septum
o
Case Four: facial pain or headache
o
Case Five: other pathology
o
Case Six: other pathology
Neurological CT
BRAIN ONLY
o
Case One: brain – stroke or bleed
o
Case Two: brain – tumor
o
Case Three: brain – trauma
o
Case Four: brain – other pathology
o
Case Five: brain – other pathology
o
Case Six: brain – other pathology
Examples of other pathology to be submitted if cases not
available from list above:
o
Nasal obstruction
o
Polyposis
o
Anosmia
o
Chronic posterior epistaxis
SINUS AND TEMPORAL BONE
o
Case One: temporal bone - tumor
o
Case Two: temporal bone - mastoiditis
o
Case Three: sinus - sinusitis
o
Case Four: sinus - DNS
o
Case Five: sinus, temporal bone, soft tissue neck (if
performed) or chest (if performed) with other pathology
o
Case Six: sinus, temporal bone, soft tissue neck (if
performed) or chest (if performed) with other pathology
Acute Stroke Imaging – submit two acute stoke head CT
exams and answer the Acute Stroke Imaging questions in the
application. Refer to the appendix in the IAC Standards and
Guidelines for CT Accreditation for guidance»
BRAIN AND SPINE
o
Case One: brain – stroke or bleed
o
Case Two: brain – tumor
o
Case Three: brain – other pathology
o
Case Four: spine – herniated disc
o
Case Five: spine – other pathology
o
Case Six: spine – other pathology

Body CT
o
o
o
o
o
o
Case One: abdomen (i.e., liver or kidney or pancreas)
demonstrating pathology
Case Two: pelvis (i.e., ovaries or prostate)
demonstrating pathology
Case Three: chest (non-cardiac) demonstrating
pathology
Case Four: extremity case with reformats in plane
according to facility protocol demonstrating pathology
Case Five: abdomen or pelvis with other pathology
Case Six: body anatomy with other pathology
Sinus and Temporal Bone CT

Vascular CTA
o
o
o
o
o
o
Case One: extracranial carotid artery - axial, coronal,
sagittal and 3-D reconstructed views
Case Two: arch, descending thoracic, and abdominal
aortic imaging axial, coronal, sagittal and 3-D
reconstructed views - 1-2 mm cuts
Case Three: endovascular repair of the aortic arch,
descending thoracic, and abdominal aorta - axial, coronal,
sagittal and 3-D reconstructions pre-contrast, arterial and
venous phase. Include any additional CT imaging performed.
Case Four: lower extremity (i.e., femoral-plantar)
arteriogram-axial, coronal, sagittal and 3-D views
Case Five: vascular study of choice with pathology
Case Six: vascular study of choice with pathology
For complete case studies requirements, please visit intersocietal.org/ct/seeking/case_studies.htm.
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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
Freestanding imaging center
Mobile only
Other (specify):
Type of Accreditation Applying for at this Site/Location (check all that apply and indicate annual volume):
Coronary Calcium Scoring:
Coronary CTA:
Neurological CT
Brain:
Spine:
Acute Stroke:
Body CT
Chest:
Abdomen:
Pelvis:
Extremity:
Low Dose CT Lung Cancer Screening:
Sinus and Temporal Bone OR
Sinus Only
Sinus:
Sinus:
Temporal Bone:
Vascular CTA
Intracranial:
Extracranial:
Chest:
Abdomen:
Pelvis:
Peripheral/Extremity:
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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
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, 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 CT procedures at the above
listed sites/locations included in the current CT 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 CT equipment
used at any of the above sites/locations?
Yes
No
If no, please explain:
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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
Attestation
I attest that the information provided about this site is accurate and meets the current IAC Standards and Guidelines
for CT Accreditation.
Name:
Title:
Date:
Signature: _____________________________
CT Multiple Site (Fixed and/or Mobile) Supplemental Application
Reviewed 8/3/2015
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