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Mammography Accreditation

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Table of Contents


Obtaining a New Mammography Accreditation Certificate for Each Mammography Unit

To obtain a new mammography accreditation certificate for each mammography unit at the facility, complete and submit the combination application for mammography accreditation and certification, the appropriate fees, and requested documentation. Listed below are the forms that must be submitted with all new facility applications.

Applications and Forms for New Mammography Accreditations
Document Number Title
RC 230 234 - 1 New Facility Invoice (PDF, 606KB)
RC 230 234 - 2 Mammography Application - Accreditation & Certification
RC 226-1 Business Information Form - Registration (PDF, 24KB)
RC 42-3 Radiation Safety Officer Information for Registration (PDF, 301KB)

Application, documentation, and appropriate fees must be submitted at least two 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 section 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 - As an option the following forms may be used for guidance for acceptable documents of personnel credentialing:
  • Copy of the current medical physicist’s survey report and mammography equipment evaluation requested for each mammography unit.

Digital Breast Tomosynthesis

If the mammography unit will be used to perform digital breast tomosynthesis:

  • Contact the FDA at the following link for Digital Breast Tomosynthesis approval. (The facility must receive approval from the FDA prior to using the digital breast tomosynthesis portion of the mammography unit.)
    Food and Drug Administration Logo FDA Certification Extension Program - Digital Breast Tomosynthesis System
  • When the FDA Tomosynthesis Approval Letter is received the facility may begin to use the Digital Breast Tomosynthesis portion of the unit.
  • Submit a copy of the FDA Tomosynthesis Approval Letter to the Mammography Certification Program.

Fee Schedule for Mammography Accreditation

Each application for a new mammography accreditation shall be accompanied by a non-refundable fee. Fee payments by check or money order shall be made payable to the Texas Department of State Health Services. Note: if a mammography unit fails the image review process, there will be additional fees.

Mammography Accreditation fees are per mammography unit

Fee Schedule for Mammography Accreditation
Accreditation Type Fee
First mammography unit $1,025
Each additional machine at the facility $610

Mammography Accreditation Renewals

Facilities accredited with 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) 834-6688 extension 2246.


Name and/or Ownership Change

Due to all of the variables in an ownership and/or name change, contact the Mammography Accreditation Program at (512) 834-6688 extension 2246 for more information.


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

Complete the appropriate sections of the mammography certification application: RC 230-1, Application for Mammography Certification - New Facility or Renewal (PDF, 137KB), and submit to the Mammography Program.


Mammography Equipment Changes

To Add a Mammography Unit

Contact the Mammography Accreditation Program, at least 30 days prior to installation of the mammography unit, for information regarding the required documents, the correct forms and fees. Depending upon where the facility is in the mammography accreditation process, the facility may be required to undergo early renewal of its accreditation for all of the mammography units at the facility.

To Delete a Mammography Unit

Complete and submit RC 18-M, Mammography Transfer-Disposal Form (PDF, 17KB)


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

All personnel changes must be submitted to the Mammography Certification Program except the Accreditation Contact which is sent to the Mammography Accreditation Program. Prior to employing the individual(s), the facility must verify and maintain copies of qualifications for review by the agency.

  • Accreditation Contact person - Notify the agency in writing within 30 days of additions or deletions of accreditation contact individual.
  • Radiation Safety Officer (RSO) - Notify the agency in writing within 30 days by completing and submitting either of the following forms. Submit credentials if required.

    Required Forms for Mammography Radiation Safety Officer (RSO) Changes
    Document Number Document Title
    RC 230-2 Amendment Application for Mammography Certification (PDF, 131KB)
    RC 42-3 Radiation Safety Officer (RSO) Form (PDF, 301KB)
  • 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 230-2 Amendment Application for Mammography Certification (PDF, 131KB)
    RC 230 43-M Lead Interpreting Physician (LIP) Form (PDF, 230KB)
  • Other Personnel Changes (Interpreting Physicians, Mammography Technologists and/or Medical Physicists) - Notify the agency in writing within 30 days of additions or deletions.

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 and Accreditation

To terminate a mammography certification and accreditation, complete and submit form RC 17-M, Termination of Certification of Mammography Systems (PDF, 17KB)


Contact Information

Mailing Address (U.S. Postal Service)

Texas Department of State Health Services
Radiation Safety Licensing Branch, MC 2003
P. O. Box 149347
Austin, Texas 78714-9347

Mailing Address (Overnight Address)

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

Phone: (512) 834-6688 ext. 2246
Fax: (512) 834-6716 or (512) 834-6617


Additional Information

For additional information see the Mammography Frequently Asked Questions page, or contact the mammography accreditation program at (512) 834-6688 ext. 2246.

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Last updated January 29, 2016