Application Forms

Technologists Application Forms

• Attestation Forms
  • Attestation of Employee Training
  • Attestation of Safe Injection Training
  • Facility Attestation of Employee Licensure

• License Application Forms
  • License
  • Limited License
  • Student License

• Registration Application Forms
  • Registration Form for CT or Fluoroscopy prior to 1-1-2020
  • Registration Form for Radiation Therapy or Radiologic Imaging prior to 1-1-2020.
  • Registration form for Rural Authorization
  • Registration Form for the holder of a license to engage in Computed Tomography for Qualifying.
  • Registration Form for the holder of a license or limited license to practice outside of scope

Mammography Application Forms

General Forms

• Notice to Employees Form
• Mammographer Certificate of Authorization Application (Click here to access our online system)
• Mammography Technologist Change of Information (Click here to access our online system)
• Mammography Technologist Termination Request (Click here to access our online system)
• Mammography Machine Application for Certificate of Authorization (Click here to access our online system)
• Mammography Machine Application for Certificate of Authorization - Addendum 1
• Mammography Machine Application for Certificate of Authorization - Addendum 2
• Mammography Machine Application for Certificate of Authorization - Addendum 3
• Non-MQSA Mammography Machine Annual Registration Form
• Mammography Physicians Supplement
• Template for Physician Experience

Mammography Guidance

• Basic Operational Requirements for Mammography
• Common Mammography Violations
• Adding and Deleting of Interpreting Physicians
• Model Letter for Adding a New Mammography Physician