ACR Accreditation Mobile Unit / Leased Time Scenario Request Form

Review eligibility requirements prior to form submission: https://accreditationsupport.acr.org/support/solutions/articles/11000051009-mobile-unit-multi-site-policy
Submit this form to determine eligibility
An ACR Accreditation Assistant will review and then contact you with next step instructions

Is this for mobile or leased time units?*

Select

Modality*

Select

Primary Facility Modality ID*

e.g. 1235 or 60571

Primary Facility Name*

Primary Facility Address*

How many mobile units are you applying for?*

Unit 1 Make*

Unit 1 Model*

Unit 1 Serial Number*

Serial numbers on this form must match those in ACRedit

Unit 2 Make*

Unit 2 Model*

Unit 2 Serial Number*

Unit 3 Make*

Unit 3 Model*

Unit 3 Serial Number*

Unit 4 Make*

Unit 4 Model*

Unit 4 Serial Number*

Unit 5 Make*

Unit 5 Model*

Unit 5 Serial Number*

How many secondary sites are using the unit(s)?*

This form accepts a maximum of 6 secondary sites. If you have more than 6, please submit this form for the first 6, then submit a new form for the remaining sites.

Modality ID of Secondary Site 1/Leasing Entity

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 1/Leasing Entity*

Address of Secondary Site 1*

Date this location/entity began using the unit(s)*

If this site uses multiple units enter the earliest date any of them were used

Which unit(s) are used at this location?*

Select

Name of the Supervising Physician at the Leasing Entity*

Modality ID of Secondary Site 2

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 2*

Address of Secondary Site 2*

Date this location began using the unit(s)*

If this site uses multiple units enter the earliest date any of them were used

Which unit(s) are used at this location?*

Select

Modality ID of Secondary Site 3

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 3*

Address of Secondary Site 3*

Date this location began using the unit(s)*

If this site uses multiple units enter the earliest date any of them were used

Which unit(s) are used at this location?*

Select

Modality ID of Secondary Site 4

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 4*

Address of Secondary Site 4*

Date this location began using the unit(s)*

If this site uses multiple units enter the earliest date any of them were used

Which unit(s) are used at this location?*

Select

Modality ID of Secondary Site 5

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 5*

Address of Secondary Site 5*

Date this location began using the unit(s)*

Which unit(s) are used at this location?*

Select

Modality ID of Secondary Site 6

e.g. 1234 or 60513. If this is a new facility leave blank

Facility Name of Secondary Site 6*

Address of Secondary Site 6*

Date this location began using the unit(s)*

If this site uses multiple units enter the earliest date any of them were used

Which unit(s) are used at this location?*

Select

Each secondary location has at least one interpreting physician who also reads at the primary location.*

All entities use the same interpreting physicians*

All locations/entities use the same scanning protocols*

All entities use the same Technologists*

All entities will perform the same modules/patient types*

The billing will be done under DIFFERENT numbers than the accredited facility?

National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN)

To process this application we must receive a signature from a staff member at the Primary facility. Who will be signing?*

Only the Supervising Physician or Facility Administrator listed on your account in the ACRedit system may sign.

Note: if this is a Leasing Request you must select Supervising Physician.

Select

Signer's name*

Provide an email address for the person providing their signature.*

This person will receive an email from DocuSIgn. Please alert them that this email will be coming.

Your name*

Your email*

Send me a copy of my responses

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