Information Needed for Your Application (Revised 12-12-19)

Katie Albus

Modified on: Thu, 26 Jan, 2023 at 8:43 AM

Revision History

Please see our separate article: Information Needed for Your Application: Mammography

If this is your first time applying for accreditation at a location, you will need all information detailed in the table below. If this is a renewal or reinstate application, the accreditation system will pre-populate previously submitted data. If any information has changed since the last application, please change it in your application. You will not be able to make changes once the application is submitted.

Section 1: Facility Information

Section 2: Modality Information

Section 3: Personnel, Payment and Submission

Information in this section should be true for all types of imaging at your location. Do not enter modality-specific contacts; this information will reflect on all modalities at the practice site.

Facility name
Location address
Facility supervising physician
Facility administrator
CMS information (if applicable)
Survey agreement cosigners

Information specific to the imaging modality for which you are applying. You may enter a contact name on the attention line of the mailing address on this section.

Modality supervising physician (may differ from facility supervising physician)
Technologist contact person
Unit details (number of units, make/model, serial number, most recent annual system evaluation date, submission type, and patient types – if applicable – for submission)

Personnel: List interpreting physicians, physicists (if applicable), and technologists operating under the applied modality. For per diem details, please review the modality program requirements.
Payment: details are available here.

The ACR accepts faxed, electronic, or digital signatures for accreditation applications. These will be treated as legally binding.

You may be asked to provide an estimate of the average number of procedures conducted at your facility per year. If you are a new facility applying for a breast imaging modality, you may be asked to submit all the patient volume and outcome data you have available into your online application.

For facilities subject to MIPPA requirements, the application requires your facility’s Employee Identification Number (EIN). Also known as a “Federal Tax ID Number”, your EIN is a 9-digit number that the IRS assigns in the following format: 12-3456789. The IRS uses the number to identify taxpayers who are required to file various business tax returns. You must also use your EIN when filing a CMS (Medicare) claim. EINs are used by employers, sole proprietors, corporations, partnerships, nonprofit organizations, trusts, estates of decedents, government agencies, certain individuals, and other business entities. You should ask your business office for your facility’s EIN number.

New facilities will be assigned a unique identification number after the online application is submitted. This number appears on all correspondence from the ACR and on your online records. Please use this number on all submitted materials and to identify your facility when contacting the ACR for assistance.

After your application and payment are processed, an online testing packet will be activated which will contain all of the clinical and, if applicable, phantom data forms required for accreditation review. Your facility will receive an e-mail with a link to the online testing packet as well as your modality’s Quality Control Manual (if applicable).

Revision History for this Article
Date	Section	Description of Revision(s)
12-12-19	All	Article created; FAQs incorporated; No criteria changes

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