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Mammography Accreditation

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 226-01 Business Information Form - Registration (PDF, 271KB)
RC 42-R Radiation Safety Officer Information for Registration (PDF, 316KB)

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:
    • Clinical Image Quality Procedures - 289.230 (u) & (u)(1)(B)(i)
      • Ensuring image quality, and corrective actions to be taken if images are of poor quality.
      • Ensuring the interpreting physicians follow image quality procedures when images are of poor quality.
      • Review of clinical images for image quality performed by all active mammography technologists and interpreted by interpreting physicians at the facility.
      • Lead Interpreting Physician Oversight
    • 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 Systems (DBT)

The FDA has approved the State of Texas accreditation body (STX AB) to accredit Digital Breast Tomosynthesis beginning April 9, 2018.

  • STX accredited facilities that are currently undergoing, the accreditation process and have a DBT unit, must add the DBT unit(s) to your accreditation during this current reaccreditation (renewal) process.  Once approved, all of your units will receive an accreditation expiration date that is three years from your current expiration date.  If your facility has recently completed the reaccreditation process, the Agency will contact you with instructions to add the DBT unit to your accreditation.  
  • STX accredited facilities with MQSA certificates that expire within the next 8 months will add the DBT unit(s) to your accreditation at the time of renewal. Your facility must renew the accreditation for all your existing mammography units, as well as accredit your DBT unit(s) at this time. Once approved, all your units will receive a STX accreditation expiration date that is three years from your current expiration date. 
  • STX accredited facilities with more than 13 months left on their MQSA certificate will add the DBT unit(s) to their accreditation at the time of renewal. 

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
Each DBT mammography unit at the facility $330

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) 218-7087.

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) 218-7087 for more information.

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

Complete the appropriate sections of the mammography certification application: RC 230 234-02, Mammography Application & Certification Application, 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, 718KB)

Accreditation Contact Changes

Contact the Accreditation Program in writing within 30 days of change, providing the contact name, phone number, and email address.

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, 759KB)

Contact Information

Mailing Address (U.S. Postal Service)

Texas Department of State Health Services
Radiation Section, Mammography Branch MC 1986
P. O. Box 149347
Austin, Texas 78714-9347

Mailing Address (Overnight Address)

Texas Department of State Health Services
Radiation Section, Mammography Branch MC 1986
1100 West 49th Street
Austin, Texas 78756

Phone: (737) 218-7087
Fax: (512) 206-3787

Additional Information

For additional information see the Mammography Frequently Asked Questions page.

Radiation Control

Radiation Control

Mammography