Technologists Application Program - Forms

Online Website Register/Renewal

INFORMATIONAL NOTICE

• Change of Address Form
• Name Change Form
• Recognized Continuing Education Organizations

Attestation Forms

• • Attestation of Employee Training
  • Attestation of Safe Injection Training
  • Facility Attestation of Employee Licensure
  • Rural Authorization Registration Form
  • Credential Verification
  • Registered Cardiovascular Invasive Specialist (RCIS) - Fluoroscopy Training and Experience

License Application Forms

• • Full License (Click here to access our online system)
  • Limited License (Click here to access our online system)
  • Student License (Click here to access our online system)

Registration Application Forms

• • Registration Form for CT or Fluoroscopy prior to 1-1-2020 (Click here to access our online system)
  • Registration Form for Radiation Therapy or Radiologic Imaging prior to 1-1-2020 (Click here to access our online system)
  • Registration form for Rural Authorization (Click here to access our online system)
  • Registration Form for the holder of a license to engage in Computed Tomography for Qualifying (Click here to access our online system)
  • Registration Form for the holder of a license or limited license to practice outside of scope (Click here to access our online system)

Technologists Fees

Per LCB File No. R043-20 and R074-19, Adopted Regulations

• Technologists Licensing and Registration Fees

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
• Guidance Document Annual Registration of Mammography Machines