Adding A Testing Area (EP - Device Clinic)

Cardiac Electrophysiology - Device Clinic
Complete the following form to apply for device clinic accreditation.
Application Number
*If you are currently accredited in another area by IAC Cardiac Electrophysiology. If not applicable, type N/A.
Primary Site Name
Primary Site Address

Street Address

Suite / Department

CityState / Province

Postal / Zip Code
Where is your primary site located?

Other
If hospital selected, please enter number of beds.
Your Name

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

Enter the number of device clinic post-procedural onsite and longitudinal remote monitoring of implantable devices performed over the preceding 12-month period.
Device Clinic post-procedural onsite and longitudinal remote monitoring of implantable devices.
Does the Medical Director interpret post-procedural onsite and longitudinal remote monitoring of implantable devices at your facility?
If yes, enter name:
Annual Volume
Enter the average annual volume of post-procedural onsite and longitudinal remote monitoring of implantable devices interpreted by the Medical Director in this laboratory.

Please list the medical staff that perform post-procedural onsite and longitudinal remote monitoring of implantable devices and their individual volumes.

Rows	Interpreting Physician	Annual Device Clinic Volumes
Staff # 1
Staff # 2
Staff # 3
Staff # 4
Staff # 5
Staff # 6
Staff # 7
Staff # 8
Staff # 9
Staff # 10

Attach a copy of the laboratory-specific, Device Evaluative Clinic protocol. (Applicable Standard: Part B, 1.11.6B)

Browse Files
Attach Word, PDF or Excel. Cancelof

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

Additional case studies and documentation are required. A staff member will contact you regarding additional required documentation and case study submission.
Please verify that you are human
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Cardiac Electrophysiology - Device Clinic