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New IDEAS: PET Facility Site Feasibility Questionnaire
General PET Facility Information
1.
Name of PET Facility
2.
Type of Facility
Hospital-based facility accredited by a Medicare-approved hospital-accrediting body (i.e. Joint Commission, DNV)
Not hospital-based (physician office or Independent Diagnostic Testing Facility)
3.
Is your facility accredited for brain PET?
Yes (accredited by American College of Radiology (ACR), Intersocietal Accreditation Commission (IAC), RadSite)
No
4.
Is your facility eligible to bill for Medicare services?
Yes
No
5.
Did your facility participate in the original IDEAS Study?
Yes
No
6.
How many Brain PET with F-18 fluorodeoxyglucose (FDG) studies did your facility perform during the past 12 months?
Less than 25
26 - 50
51 - 75
76 or more
7.
Physical Address of Facility
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number