Frequently Asked Questions about Mammography Certification

Mammography Personnel

How do I add mammography personnel – interpreting physician(s), mammography technologist(s) and/or medical physicist(s)? Do I need to send credentials when adding personnel?

Submit a signed, written request within 30 days of the change indicating the name of the individual the facility would like to add. Credentials do not need to be submitted with the request. However, prior to employing the individuals, facilities must verify and maintain qualifications for review at the time of their annual inspection.

How do I remove mammography personnel?

Submit a signed, written request within 30 days of the change indicating the name of the individual the facility would like to remove.

Do I need to add locum tenens physicians and/or temporary mammography personnel to the facility’s certification?

Facilities utilizing interpreting physicians or technologists from a temporary service shall verify credentials prior to employing these individuals and maintain copies of the qualifications for inspection by the Agency. The facility does not need to notify the Agency unless these personnel will be at the facility for a period exceeding four weeks.

How do I change the Radiation Safety Officer (RSO)?

Notify the Agency in writing within 30 days by completing and submitting a RC 42-R Radiation Safety Officer (RSO) Form . Forms not completed or signed will delay the amendment process.

How do I change the Lead Interpreting Physician (LIP)?

To request a LIP change, the facility must notify the Agency certifying body in writing within 30 days and include a signed statement from the LIP accepting responsibility for the quality assurance program.

Can a facility have two lead interpreting physicians that share joint responsibility?

No. There can only be one designated lead interpreting physician.

The facility is changing the accreditation contact person, who do we have to contact?

Contact the facility’s accrediting body for instructions on how to change the contact person.

Mammography Certificates

How do I get a duplicate/copy of our facility’s mammography certificate?

To request a copy of the certificate, contact the Open Records Coordinator.

Can a facility get a Spanish-language certificate?

The Agency will issue an additional certificate translated into Spanish for those facilities serving a Spanish-speaking population. The facility should display both Spanish and English certificates where they can be viewed by mammography patients. Contact the Agency certifying body at (737) 218-7087 to request a Spanish-language certificate.

How can I obtain a replacement original certificate and is there a fee?

Contact the Agency certifying body to request a replacement certificate. Currently, there is not a fee for a replacement certificate.

My newly issued state mammography certificate does not have an expiration date. Did I receive a valid certificate?

Yes. The expiration date is located on the first page of the two-page mammography certificate.

Our Certificate of Inspection has expired, how can I obtain a new one?

For questions regarding inspections, contact (737) 924-6835. Note: The certificate of inspection does not authorize the facility to perform mammography.

New Facilities, Renewals, and Name/Address Changes

We are opening a new mammography facility. What application do we need to submit and how long will the process take?

Contact the Mammography Certification Program at least 30 days prior to the facility opening date at (737) 218-7087.

What is the process for adding a mammography unit?

Contact the Mammography Certification Program at least 30 days prior to installing the new mammography unit at (737) 218-7087.

When will the facility receive their renewal application?

For facilities accredited with the American College of Radiology, the certification renewal application is mailed out 60 days prior to the expiration date. However, if the facility is accredited with the Texas Mammography Accreditation Program, the facility will receive a combination renewal application 7-9 months prior to the facility’s expiration date.

What do we do for an ownership and/or name change?

Due to all of the variables in an ownership and/or name change, contact the Mammography Certification Program at (737) 218-7087 for more detailed information.

We are moving to a new location. What application and/or forms do we need to submit?

Due to all of the variables when moving to a new location, contact the Mammography Certification Program at (737) 218-7087 for more detailed information.

What name(s) are we supposed to put on the Business Information Form

The RC 226-01 Business Information Form should state the ‘Legal Name’ and ‘Doing Business As’ name, if applicable, as filed with Texas Secretary of State’s Office and/or county clerk’s office.

I have submitted my annual certification fees. When can I expect to receive my new certificate?

Paying annual fees does not constitute issuance of a new certificate. You will not receive an amended certificate until after your next renewal period.

How can I verify that the Agency has received my amendment request?

Contact the Radiation Machine Source Group at (737) 218-7087 to verify receipt.

The facility received a Notice of Violation for non-payment of fees, who do I need to contact?

Contact the Accounting Department at (737) 231-7627.

We would like to add mobile service authorization to our certification. What application and/or forms do we need to submit?

Complete and submit a RC 230-02 Mammography Certification Application Amendment sections 1, 2, and 6. Facilities shall not provide mobile services prior to receiving authorization from the Agency.

We would like to add self-referral to our certification. What application do we need to submit?

Complete and submit a RC 230-02 Mammography Certification Application Amendment sections 1, 2, and 6.

Training and Credentials

Does a mammography technologist need to hold the ARRT advanced mammography registry to perform mammography?

No, it is not required for a mammography technologist to hold the ARRT (M). However, the mammography technologist must have completed the initial 40 hours of mammography training.

Can a facility provide in-house training for mammography?

Yes. In-house training can be obtained under the supervision of a qualified instructor. At least 40 contact hours of documented training specific to mammography must be completed. The hours of documented training shall include, but is not limited to:

• Training in breast anatomy and physiology, positioning and compression, quality assurance/quality control techniques, imaging of patients with breast implants;
• The performance of a minimum of 25 examinations under the direct supervision of an qualified individual and;
• At least 8 hours of training in each mammography modality to be used by the technologist in performing mammography exams.

Can an interpreting physician overread/multi-read to meet their continuing experience requirement?

Yes, as long as the interpreting physician did not interpret the original mammogram.

Operating Procedures

When a facility is requesting digital mammography films for comparison, can the facility accept images on a CD or can they obtain hardcopy films?

For purposes of transferring films, the facility must be able to provide the medical institution, physician, healthcare provider, patient or patient’s representative, with hardcopy films of final interpretation quality or, when it is acceptable to the recipient (e.g., a transfer between two FFDM facilities), with original or lossless compressed full field digital images electronically.

When a diagnostic mammogram is performed, does an interpreting physician have to be present?

No, currently there is no regulation that requires an interpreting physician to be onsite at the time a diagnostic mammogram is performed.

Transfer and Termination

We will be terminating our mammography certification. What form do we need to submit?

Notify the facility’s accreditation body. Complete and submit a RC 17-M Termination Form to the Agency.

We are transferring our mammography unit to a different facility. What application and/or forms do we need to submit?

At least 30 days prior to the move, contact the facility’s accreditation body for detailed instructions. In addition, contact the Mammography Certification Program at (737) 218-7087.