Comprehensive Breast Imaging Center
Application Request

In order to be eligible for the ACR’s Comprehensive Breast Imaging Center (CBIC) designation, a center must be ACR accredited in:

Mammography, and
Stereotactic breast biopsy, and
Breast ultrasound and Ultrasound-guided breast biopsy, and
MRI accreditation in the breast module

An authorized account user from the home facility must sign the request. Please advise the authorized user you enter below that they will receive an email from Docusign shortly after this form is submitted to digitally sign.

Only one MAP ID may be on the application and must be specified as the home facility.

Reason for requesting ACR designation as a Comprehensive Breast Imaging Center:

If your center has affiliated accredited facilities at different physical locations - These facilities must be fully accredited in all breast imaging services provided to be considered part of the Comprehensive Breast Imaging Center. With appropriate verification, the ACR will recognize the facility as an affiliate of a Comprehensive Breast Imaging Center. Affiliates must designate one of their ACR-accredited facilities as their center’s “home facility” for the ACR to use as a point of contact.

Our center is currently accredited in all required breast imaging modalities but under different names.

Our center has affiliated accredited facilities at different physical locations

In addition to your home facility, how many additional facilities do you have?

Center’s Home Facility

Breast Imaging Center's Home Facility Name

Home Facility Address

Officer or Owner:

Lead Interpreting Physician:

Submitter Name

Submitter phone

Phone

Submitter email

Signer's Name

An authorized account user from the home facility must sign the request. Please advise the authorized user you enter below that they will receive an email from Docusign shortly after this form is submitted to digitally sign

Signer's Role

Signer's Email

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﻿Comprehensive Breast Imaging Center Application Request

Center’s Home Facility

Comprehensive Breast Imaging Center
Application Request