Adding A Testing Area (Echo

Adding a Testing Area

Echocardiography - Adult Congenital Transthoracic
Complete the following form for any accredited sites that you wish to add a new testing area for an existing accreditation.
Application Number*
*From your currently accredited IAC Adult Echocardiography accreditation account.
Primary Site Name*
*Must match the facility name entered in your online application.
Primary Site Address*

Street Address

Suite / Department

CityState / Province

Postal / Zip Code
Where is your primary site located?*

HospitalPhysician Office (outside of hospital)Multispecialty ClinicIndependent Facility (e.g., IDTF)Other
Your Name*

First NameLast Name
Your Title*
Your E-mail Address*
example@example.com

Attestation
By signing below, I ({yourName}) attest that the information provided about this facility is accurate and meets the current IAC Echocardiography Standards.
Signature*

Clear
Please verify that you are human*
Hitting "submit" below will send your application to IAC. Please wait until you see a confirmation prior to closing your browser window.
Should be Empty:

	Interpreting Physician	Annual ACTE Volumes	Experience Pathway* (Enter 1.9.1.1A or 1.9.1.2A)	Meets CME Requirement?*** (Enter Yes or No)
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	Congenital Technical Staff Name	Meets CME Requirement?* (Enter Yes or No)	Annual ACTE Volumes
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	Provisional Congenital Technical Staff Name	Start Date of Adult Congenital Training (MM/DD/YEAR)
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