Form CMS-10152 PET Facility Registration Form

[0938-0968 FORM #1]
PET Facility Registration Form
National Oncologic PET Registry
•

Please complete this form to finalize the NOPR registration process.

•

Once this completed form is submitted, a confirmation e-mail will be sent with an invoice for the
escrow account start-up funds and the $50 application fee.

•

When the start-up funds are received at NOPR Headquarters an escrow account will be established
for the PET Facility. $50 will be debited from this account each time the facility registers a case on the
NOPR. E-mail reminders will be sent to the PET Facility Administrator when the account balance dips
below a minimum level as defined by the Facility on this Registration Form.

•

The PET Facility can pay the $50 registration fee and initial escrow deposit either by:
o Mailing a check made payable to ACR-NOPR together with a copy of the e-mailed invoice to the
American College of Radiology, 1818 Market Street, Suite 1600, Philadelphia, PA 19103. The
facility ID# must be written on the check; or
o Paying by credit card using the information in the e-mailed invoice and confirmation to log into
the facility’s account on the NOPR Web site.

•

Once the ACR receives the facility registration fee and the executed Business Associates Agreement
(BAA), the PET Facility will be sent an e-mail approval notice and the facility will be eligible to
participate in the National Oncologic PET Registry via the secure Web site.
Only cases that meet the criteria listed in the Coverage Decision will be eligible for registration and CMS
reimbursement.

Facility ID #:
1. PET FACILITY INFORMATION
Name of Imaging Center (will be supplied by the system from pre-registration information) _________________
Mailing Address

(street 1)

(street 2)

(city)

(state)

Telephone

x

(zip)

FAX:

Business entity responsible for payment
Medicare Provider Number or National Provider Identifier Number:
PHYSICAL ADDRESS OF THE PET FACILITY
Address

(street 1)

(street 2)

(city)

Telephone

(state)

(zip)

x

2. PET FACILITY ADMINISTRATOR
Official facility contact person for the National Oncologic PET Registry (will be supplied by the
system from pre-registration information)

E-mail address (will be supplied by the system from pre-registration information)
3. PARTICIPATING PHYSICIANS - who will interpret PET scans. (Web form will accept as
many as needed)

First Name __________________

Last Name ________________ NPI ________________________

First Name __________________

Last Name ________________ NPI ________________________

4. STAFF - People who are allowed to register patients and enter data into the database. A
username and password will be emailed to the staff person.
First Name __________________

Last Name ________________ E-mail ______________________

First Name __________________

Last Name ________________ E-mail ______________________

5. EQUIPMENT DESCRIPTIONS – Provide complete information for each PET scanner. (Web
Form will allow for entry of multiple scanners)
Facility’s Scanner Identifier (facility’s name for scanner)
Manufacturer

Model

 Fixed

 Mobile

 Hospital-Based

 Not hospital-based (independent diagnostic testing facility)

6. CALCULATION OF ESCROW ACCOUNT
Payment to the National Oncologic PET Registry for each case entered into the database
for CMS reimbursement is required in advance. It is recommended that each facility
schedule monthly payments based on the expected number of cases registered for one
month. You may stop participating in the Registry at any time. Upon letter to the Program
Manager any unexpended credit balance will be refunded.
Invoice will be E-mailed to registering facility in the amount calculated below.
Initial Facility registration fee:
Number of cases to prepay @ $50
each:

$50
x $50 =

Total:
7. FUND BALANCE REMINDER
PET Facilities can monitor the balance remaining in their NOPR Account via the secure
Website. New cases can be registered as long as there is a positive balance remaining. It is
recommended that each facility maintain a credit balance at all times commensurate with the
facility’s caseload. An E-mail reminder will be sent from the Registry when your fund
balance reaches the minimum threshold established by the PET Facility.
Please notify our PET Facility when our account balance with the ACR reaches the level
selected below:
 $250 – 5 cases remaining
 $500 – 10 cases remaining
 $1,000 – 20 cases remaining
 $2,000 – 40 cases remaining
8. HAS THE BUSINESS ASSOCIATE AGREEMENT (BAA) BEEN EXECUTED?
 Yes

 No

(Please mail or fax (215-928-0153) the BAA to NOPR Headquarters. Note: patients cannot be
entered on the Registry until the BAA is received at Headquarters)

9. NAME OF PERSON SUBMITTING THIS FORM

First Name: ________________ Last Name: __________________
Additional information on the National Oncologic PET Registry can be found on the web site,
http://www.cancerPETregistry.org/ or by contacting the project manager at 215-717-0859.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0968. The time required to complete this information collection is estimated
to average five (5) minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.