Mammography Certification Program

Table of Contents

Obtaining a New Mammography Certification

To obtain a new mammography certification, choose either the State of Texas Mammography Accreditation Program or the American College of Radiology (ACR) as the facility's mammography accreditation body. 

    If the State of Texas will be the mammography accreditation body:

    • Contact the Mammography Accreditation Program at (512) 231-5700 at least 30 days prior to facility opening date, for information regarding the required documents, the correct forms and fees.

    If the ACR will be the mammography accreditation body:

    • Contact the ACR at 1-800-227-6440 or review their website for information. 

    Complete and submit to the Mammography Certification Program the following forms with the appropriate fee:               

     
    Document Number Document Title
     RC 230-01  Mammography Certification Application New & renewal 
     RC 226-01  Business Information Form  
     RC 42-R  Radiation Safety Officer (RSO) Form 
     RC 230 234-01  New Facility Invoice

    Application, documentation, and appropriate fees must be submitted at least three weeks prior to providing mammography services.

    ***Note: Hold the Equipment Section of the application until the mammography unit(s) is installed. Submit the completed Equipment Section page with the medical physicist survey report and mammography equipment evaluation. Forty-eight hours after receipt of the application page, medical physicist survey report, and mammography equipment evaluation, the mammography certificates will be issued.

    Each registrant shall have and implement written operation and safety procedures in accordance with Title 25 of the Texas Administrative Code (TAC) §289.230(hh)(3).

    Documentation to be submitted with the completed application:
    • Policies/procedures requested in Sections 2 of the application:
      • Corrective action procedure for poor image quality, and process for feedback from interpreting physicians: §289.230 (u) & (u)(1)(B)(i)
      • Policy for the Retention of Clinical Images for current, closed, or terminated facilities. §289.230 (t)(4)
      • Policies for self-referral if providing self-referral mammography services
      • Requested documents if providing mobile mammography services
    • Personnel credentials requested in Section 3 - As an option the following forms may be used for guidance for acceptable documents of personnel credentialing:
    • Current medical physicist’s survey report for each mammography unit 
     

    Fee Schedule for Mammography Certification

    Each application for a new mammography certification shall be accompanied by a one-year non-refundable fee. An invoice will be mailed annually for the mammography certification fee. Fee payments by check or money order shall be made payable to Texas Department of State Health Services.

    Fee Schedule for Certification of Mammography Systems (screening & diagnostic mammography)
    Certification of Mammography Systems (screening & diagnostic mammography) Fee
    First machine $2,010
    Each additional machine listed on certification $240

    Annual Fees for Mammography Certification

    Annual fees must be paid each year in order to continue operating mammography devices. The fee covers all direct and indirect costs associated with licensing a company or individual.

    For detailed information on annual fees and payment methods accepted, see Payment of Annual Fees for Mammography Certification or Interventional Radiography.

    Mammography Certification Renewals

    Mammography certification renewal documentation shall be submitted every three years.

    The agency will send a renewal reminder letter and application by mail 2-3 months prior to the expiration date of the mammography certification. Items requested for a mammography certification renewal are:

    Required forms for mammography certification renewal
    Document Number Document Title
     RC 230-01  Mammography Certification Application - New & Renewal  
     RC 226-01  Business Information Form  

    Documentation to be submitted with the completed application:

    • Applicable policies/procedures requested in Section 2 of the application.
    • Current medical physicist’s survey report for each mammography unit.

    Facilities Accredited with the State of Texas

    Facilities accredited with the State of Texas will receive the renewal application, invoice, and instructions via email 8 months prior to the expiration date listed on the facility’s mammography certificates. If renewal email is not received by 6 months of the expiration date, contact the Texas Mammography Accreditation Program at (512) 231-5700.

    Name and/or Ownership Change

    Due to all of the variables in an ownership and/or name change, contact the Mammography Certification Program at (737) 218-7110 for more information.

    To Change a Mailing and/or Physical Use Location Address(s)

    Mammography Equipment Changes

    To Add a Mammography Unit

    If accredited with State of Texas

    • Contact Mammography Accreditation Program at (512) 231-5700 at least 30 days prior to installation of the mammography unit, for information regarding the required documents, the correct forms and fees.

    If accredited with the American College of Radiology (ACR)

    Dual modality mammography machines (2D and DBT) are considered two separate units.  Both modalities must be accredited.  Contact your accreditation body for instructions.

    To Delete a Mammography Unit

    Personnel Changes (Including RSO, LIP and Other Personnel Changes)

    • Radiation Safety Officer (RSO) - Notify the agency in writing within 30 days by completing and submitting either of the following forms:
       
      Required Forms for Mammography Radiation Safety Officer (RSO) Changes
      Document Number Document Title
       RC 230-02  Mammography Certification Application Amendment 
       RC 42-R  Radiation Safety Officer (RSO) Form 
    • Lead Interpreting Physician (LIP) - Notify the agency in writing within 30 days by completing and submitting either of the following forms:
       
      Required Forms for Mammography Lead Interpreting Physician (LIP) Changes
      Document Number Document Title
       RC 230-02  Mammography Certification Application Amendment
       RC 230-LIP  Lead Interpreting Physician 
    • Other Personnel Changes (Interpreting Physicians, Mammography Technologists and/or Medical Physicists) - Notify the agency in writing within 30 days of additions or deletions of personnel. Do not submit credentials with the request. Include the facility’s mammography certification number.  Letter must be signed by the RSO, LIP, or CEO of he facility.
    • Accreditation Contact Person - Contact the State of Texas Mammography Accreditation Program (see the Mammography Accreditation page for more information) or the American College of Radiology.

    Self-Referral Authorization

    Self-referral authorization must be obtained prior to initiating self-referral mammography services.

    To add self-referral authorization to the certification, submit:

    To remove self-referral authorization:

    • Notify the agency in writing by submitting a signed letter requesting removal of self-referral authorization.
    • Include the facility’s mammography certification number.

    Mobile Services Authorization

    Mobile service authorization must be obtained prior to providing mobile mammography services.

    To add mobile service authorization to the certification, submit:

    To remove mobile service authorization:

    • Notify the agency in writing by submitting a signed letter requesting removal of mobile service authorization.
    • Include the facility’s mammography certification number.

    Terminating a Mammography Certification

    To terminate a mammography certification:

    • Contact the facilities mammography accreditation body (State of Texas Mammography Accreditation Program or the American College of Radiology - ACR).
    • Complete and submit RC 17-M Mammography Termination.

    Mammography Certification Contact Information

    Mailing Address (U.S. Postal Service)

    Texas Department of State Health Services
    Registration Branch, Radiation Section, MC 2003
    PO Box 149347
    Austin, Texas 78714-9347

     

    Mailing Address (Overnight Address)

    Texas Department of State Health Services
    Registration Branch, Radiation Section, MC 2003
    1100 West 49th Street
    Austin, Texas 78756

    Phone: (737) 218-7110

    Fax: (512) 2063787

    Additional Information

    For additional information see Frequently Asked Questions about Mammography Certification, or contact the Mammography Certification Program at (737) 218-7110

    Texas Radiation Control

    Texas Radiation Control

    Mammography