ARRA-13 https://arra.az.gov Phone (602) 255-4845
June 2017 4814 S. 40
St. Phoenix, AZ. 85040. email@example.com
ARIZONA RADIATION REGULATORY AGENCY
APPLICATION FOR MAMMOGRAPHY SCREENING AND SELF REFERRAL
Does your facility perform screening mammography?
If you answered no then you do not need to submit this form.
Check appropriate selection and provide registration number if currently registered.
Are you a MOBILE facility?
Location of image interpretation
Lead Interpreting Physician’s name
Does the facility conduct Self‐referral mammography screening exams?
If yes, provide the physician approved policy for accepting self‐referral patients.
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.