Standards Exception Form

IAC guidance form related to utilization of new technology not currently addressed in the IAC Standards.

New or emerging technologies, protocols and other novel imaging or interventional approaches not included in guidelines published by professional societies must have supporting documentation that demonstrates adherence to manufacturer’s training, safety specifications and quality control specifications as applicable.
Full Name*

First NameLast Name
Phone Number

Area CodePhone Number
E-mail*
Which modality are you requesting a Standards exception?*

Vascular TestingEchocardiographyNuclear/PETMRICTDental CTCarotid StentingVascular Interventional/Vein CenterCardiac ElectrophysiologyCardiovascular Cath
Are you already IAC accredited or seeking accreditation for the first time?*

My facility is already IAC accreditedMy facility is seeking accreditation for the first timeOther
Account/Application #
Explanation of Standard exception*
Supporting documentation

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Facility Guidance for proposal submission (as applicable)

·Does this technology meet reimbursable criteria, if so what CPT code?

· What is the patient experience compared to the gold standard technology exam?

· Exam duration

· Pain tolerance

· Cost value compared to the gold standard technology exam

· Expense

· Labor, productivity
Should be Empty: