Non-VA Care Radiation Oncology Facility Profile v2.2

Dear Radiation Oncology Services Providers:

The Veterans Access, Choice and Accountability Act (VACAA) directed the establishment of the Veterans Choice Program (VCP) to better meet the health care needs of our Nation's Veterans. The law directs the establishment of a Veterans Choice Card benefit that provides a commitment to Veterans to receive healthcare in their communities if they live more than 40 miles away from a Veterans Health Administration (VHA) medical care facility. The Choice Program requires that all community-based providers must meet the VHA certification standards and must agree with the program requirements prior to rendering services to the Veterans. The National Radiation Oncology Program (NROP) of VHA has established some basic requirements for both in-house and contracted radiation oncology services to ensure quality care for our Veterans. These requirements include; practice accreditation, board-certified radiation oncologist and therapeutic medical physicist, facility credentialing for advanced radiotherapy procedures (e.g. IMRT, SRS, SBRT, and IGRT), prospective peer review, and electronic documentation of radiation treatment into CPRS (VHA Electronic Medical Record System).

Please respond to the following questions in this request for information about your practice.

If you have additional questions, please contact National Radiation Oncology Administrative Team at VHANROPAdmin@va.gov at the NROP office
National Radiation Oncology Program (11SPEC22)
Veterans Health Administration
Building 507, Room A-105
1201 Broad Rock Blvd.
Richmond, VA 23249

Thank you.

Please fill in your facility's information below and submit.

Question Title

1. Reason for submission (Required.)

Initial Request (first time submission only)

Reconsideration

Other (please specify)

Question Title

2. Contact Information (Required.)

Name of facility *

Contact person *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

Question Title

3. Other facility names and/or addresses used for current facility in the past or present?

Question Title

4. Is your facility currently accredited by ACR / ACRO / APEX? (Required.)

ACR

ACRO

APEX

None

Other (please specify)

Question Title

5. If no, when does your facility intend to apply for ACR/ACRO/APEX accreditation in the future?

Question Title

6. Number of full time Radiation Oncologist(s) on site? (Required.)

Full time?

Part time (Days/week)?

Question Title

7. Number of Board Certified Radiation Oncologist(s) on site? (Required.)

Full time?

Part time (Days/week)?

Question Title

8. Number of full time Therapeutic Medical Physicist(s) on site? (Required.)

Full time?

Part time (days/week)?

Question Title

9. Number of Board Certified Therapeutic Medical Physicist(s) on site? (Required.)

Full time?

Part time (days/week)?

Question Title

10. Number of treatment platforms (e.g. Linacs, Tomotherapy, Cyberknife, Gammaknife)? (Required.)

Question Title

11. Number of RTTs present for patient treatment / treatment platform? (Required.)

Conventional

3D CRT / IMRT / IGRT

SBRT

SRS

Question Title

12. Services offered at the facility (Required.)

Intensity Modulated Radiotherapy (IMRT)

Image Guided Radiotherapy (IGRT)

Stereotactic Body Radiation Therapy (SBRT)

Stereotactic Radiosurgery (SRS)

Total Body Irradiation (TBI)

Total Skin Electron Beam

Low Dose Rate (LDR) Brachytherapy

High Dose Rate (HDR) Brachytherapy

Other (please specify)

Question Title

13. Is radiation oncologist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

Yes

Other (please specify)

Question Title

14. Is medical physicist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

Yes

Other (please specify)

Question Title

15. Do you subscribe to independent remote output check of your Linac/s (e.g. TLDs or OSLDs)? (Required.)

Yes

Other (please specify)

Question Title

16. If yes, please specify the last independent remote output check date.

Date

Question Title

17. Are you currently credentialed by IROC - Houston for the following advanced procedures?

IMRT

SBRT

SRS

Question Title

18. If you are not credentialed by IROC-Houston for the above advanced procedures, please describe your end-to-end testing procedure.

Question Title

19. Do you treat according to ASTRO/ACR treatment guidelines for palliative care? (Required.)

Yes

Other (please specify)

Question Title

20. Which treatment guidelines do you use in your clinic? (Required.)

NCCN

Other (please specify)

Question Title

21. Which appropriate use criteria do you use in your clinic? (Required.)

ASTRO / ACR

Other (please specify)

Question Title

22. Please specify the make & model # of the Treatment Delivery Systems used at your facility. (Required.)

Question Title

23. Please specify the make and version # of the Treatment Planning Systems used at your facility. (Required.)

Question Title

24. Name, Email address & Phone Number: (Required.)

Therapeutic Medical Physicist Name:

Therapeutic Medical Physicist Email:

Therapeutic Medical Physicist Contact Phone Number:

Radiation Oncologist Name:

Radiation Oncologist Email:

Radiation Oncologist Contact Phone Number:

Question Title

25. Signature (Required.)

By checking this box you confirm that the contents of this form are reviewed and approved by your facility Therapeutic Medical Physicist.

By checking this box you confirm that the contents of this form are reviewed and approved by your facility Radiation Oncologist.

Question Title

26. Signature Date (Required.)

Date / Time

Date

Question Title

* 1. Reason for submission (Required.)

Question Title

* 2. Contact Information (Required.)

Question Title

* 3. Other facility names and/or addresses used for current facility in the past or present?

Question Title

* 4. Is your facility currently accredited by ACR / ACRO / APEX? (Required.)

Question Title

* 5. If no, when does your facility intend to apply for ACR/ACRO/APEX accreditation in the future?

Question Title

* 6. Number of full time Radiation Oncologist(s) on site? (Required.)

Question Title

* 7. Number of Board Certified Radiation Oncologist(s) on site? (Required.)

Question Title

* 8. Number of full time Therapeutic Medical Physicist(s) on site? (Required.)

Question Title

* 9. Number of Board Certified Therapeutic Medical Physicist(s) on site? (Required.)

Question Title

* 10. Number of treatment platforms (e.g. Linacs, Tomotherapy, Cyberknife, Gammaknife)? (Required.)

Question Title

* 11. Number of RTTs present for patient treatment / treatment platform? (Required.)

Question Title

* 12. Services offered at the facility (Required.)

Question Title

* 13. Is radiation oncologist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

Question Title

* 14. Is medical physicist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

Question Title

* 15. Do you subscribe to independent remote output check of your Linac/s (e.g. TLDs or OSLDs)? (Required.)

Question Title

* 16. If yes, please specify the last independent remote output check date.

Question Title

* 17. Are you currently credentialed by IROC - Houston for the following advanced procedures?

Question Title

* 18. If you are not credentialed by IROC-Houston for the above advanced procedures, please describe your end-to-end testing procedure.

Question Title

* 19. Do you treat according to ASTRO/ACR treatment guidelines for palliative care? (Required.)

Question Title

* 20. Which treatment guidelines do you use in your clinic? (Required.)

Question Title

* 21. Which appropriate use criteria do you use in your clinic? (Required.)

Question Title

* 22. Please specify the make & model # of the Treatment Delivery Systems used at your facility. (Required.)

Question Title

* 23. Please specify the make and version # of the Treatment Planning Systems used at your facility. (Required.)

Question Title

* 24. Name, Email address & Phone Number: (Required.)

Question Title

* 25. Signature (Required.)

Question Title

* 26. Signature Date (Required.)

1. Reason for submission (Required.)

2. Contact Information (Required.)

3. Other facility names and/or addresses used for current facility in the past or present?

4. Is your facility currently accredited by ACR / ACRO / APEX? (Required.)

5. If no, when does your facility intend to apply for ACR/ACRO/APEX accreditation in the future?

6. Number of full time Radiation Oncologist(s) on site? (Required.)

7. Number of Board Certified Radiation Oncologist(s) on site? (Required.)

8. Number of full time Therapeutic Medical Physicist(s) on site? (Required.)

9. Number of Board Certified Therapeutic Medical Physicist(s) on site? (Required.)

10. Number of treatment platforms (e.g. Linacs, Tomotherapy, Cyberknife, Gammaknife)? (Required.)

11. Number of RTTs present for patient treatment / treatment platform? (Required.)

12. Services offered at the facility (Required.)

13. Is radiation oncologist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

14. Is medical physicist present at the linac during the delivery of every SBRT and SRS treatment? (Required.)

15. Do you subscribe to independent remote output check of your Linac/s (e.g. TLDs or OSLDs)? (Required.)

16. If yes, please specify the last independent remote output check date.

17. Are you currently credentialed by IROC - Houston for the following advanced procedures?

18. If you are not credentialed by IROC-Houston for the above advanced procedures, please describe your end-to-end testing procedure.

19. Do you treat according to ASTRO/ACR treatment guidelines for palliative care? (Required.)

20. Which treatment guidelines do you use in your clinic? (Required.)

21. Which appropriate use criteria do you use in your clinic? (Required.)

22. Please specify the make & model # of the Treatment Delivery Systems used at your facility. (Required.)

23. Please specify the make and version # of the Treatment Planning Systems used at your facility. (Required.)

24. Name, Email address & Phone Number: (Required.)

25. Signature (Required.)

26. Signature Date (Required.)