Diagnostic Imaging Center of Excellence Application (Part 1 of 3)

In order to be eligible for the ACR’s Diagnostic Imaging Center of Excellence (DICOE) designation, a center must be accredited by the ACR in all modalities that they provide. You must also participate in the ACR's General Radiology Improvement Database (GRID) and the Dose Index Registry (DIR) if applicable. Applicants agree to an on-site survey by a team that includes a radiologist, a medical physicist and ACR staff.

Application Type

New

Renewal

Adding to the exsisting DICOE site

Master Facility Name

This name will appear on your ACR Diagnostic Imaging Center of Excellence award

Master Facility Location Address

Contact Person

Contact Phone Number

Contact Email

Facility Supervising Physician

Facility Supervising Physician Email

Quality Management Manager

Quality Management Manager Telephone

Quality Management Manager Email

Radiation Safety Officer (RSO)

Radiation Safety Officer Telephone

Radiation Safety Officer Email

Total number of facilities included in this application

Including Master Facility (Number field )

National Radiology Data Registry

Facility Master Registry Number

Facility Master Registry Name

Facility Master Registry Address

Participation Agreement Information

This DICOE Participation Agreement must be signed by the designated Supervising Physician/Medical

Director. It should also be signed by a Practice officer, owner, or other legally constituted representative of the

practice.

After submission a Participation Agreement will be sent for the DICOE program via docusign. Please indiciate below who the appropriate peope are to sign this document.

Practice Officer Authorized Signer Name

Practice Officer Authorized Signed Email

Practice Officer Authorized Signer Title

Supervising Physician or Medical Officer Name

Supervising Physician or Medical Officer Email

Supervising Physician or Medical Officer Title

Please be sure to click on the box below to get a copy of your application sent to you. You will need this in order to submit payment.

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