Section 1: Facility Information
Section 2: Modality Information
Personnel, Equipment, Payment & Submission
Information in this section should be true for your mammography facility.
Employee Identification Number (EIN)*
Facility owner, lead interpreting physician, president/CEO
Practice setting information
MQSA Information Release Authorization
Technologist contact person
Number of mammograms performed in the prior 12 months (screening, diagnostic, undifferentiated); if you are a new facility, you will be asked to submit all patient volume data available
Unit details (number of units, manufacturer/model, serial number, year manufactured, most recent equipment evaluation/physics survey)
Confirmation of all required FDA Quality Standards
Personnel: List interpreting physicians, physicists and technologists.
Equipment and QC forms relevant to the unit(s) being accredited
*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.