Fillable Facility ARIZONA RADIATION REGULATORY AGENCY APPLICATION FOR MAMMOGRAPHY (AZ Radiation Regulatory Agency)

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Facility ARIZONA RADIATION REGULATORY AGENCY APPLICATION FOR MAMMOGRAPHY (AZ Radiation Regulatory Agency)

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The Facility ARIZONA RADIATION REGULATORY AGENCY APPLICATION FOR MAMMOGRAPHY (AZ Radiation Regulatory Agency) form is 1 page long and contains:

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  • 18 check-boxes
  • 20 other fields

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File type: PDF

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ARRA-13 https://arra.az.gov Phone (602) 255-4845
June 2017 4814 S. 40
th
St. Phoenix, AZ. 85040. xray@azrra.gov
ARIZONA RADIATION REGULATORY AGENCY
APPLICATION FOR MAMMOGRAPHY SCREENING AND SELF REFERRAL
Does your facility perform screening mammography?
YES
NO
If you answered no then you do not need to submit this form.
Check appropriate selection and provide registration number if currently registered.
New
Facility
Renewal
Amendment
Date:
MM ‐
Business Name
Physical
Address
Suite
City
State
Zip
Are you a MOBILE facility?
Yes
NO
Contact Name
Title
Phone Number
Fax
Email
Type of exams performed
Screening
Diagnostic
Type of imaging system
Tomo
FFDM
CR
Film
Location of image interpretation
Onsite
Offsite
Both
Lead Interpreting Physician’s name
Physicist’s name
QC technologist’s name
Does the facility conduct Self‐referral mammography screening exams?
YES
If yes, provide the physician approved policy for accepting self‐referral patients.
NO
No additional attachments required.
The applicant or any official executing this application on behalf of the applicant certifies that this application has been prepared in accordance
with Arizona Administrative Code, Title 12, Chapter 1, and all information contained on this application, including any supplements and
attachments, is true and correct to the best of his or her knowledge and belief.
Date
Name
Signature
Title
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Facility ARIZONA RADIATION REGULATORY AGENCY APPLICATION FOR MAMMOGRAPHY (AZ Radiation Regulatory Agency)

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Completed 20 July 2020

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