Adding A Testing Area (EP - Device Clinic)

Cardiac Electrophysiology - Device Clinic
Complete the following form to apply for device clinic accreditation.
Application Number *
*If you are currently accredited in another area by IAC Cardiac Electrophysiology. If not applicable, type N/A.
Primary Site Name *
Primary Site Address *

Street Address

Suite / Department

City State / Province

Postal / Zip Code
Where is your primary site located? *

Hospital Physician Office (outside of hospital) Multispecialty Clinic Independent Facility (e.g., IDTF)
If hospital selected, please enter number of beds.
Your Name *

First Name Last Name
Your Title *
Your E-mail Address *
example@example.com

Enter the number of device clinic post-procedural onsite and longitudinal remote monitoring of implantable devices performed over the preceding 12-month period. *
Device Clinic post-procedural onsite and longitudinal remote monitoring of implantable devices.
Does the Medical Director interpret post-procedural onsite and longitudinal remote monitoring of implantable devices at your facility? *

Yes No
If yes, enter name:
Annual Volume *
Enter the average annual volume of post-procedural onsite and longitudinal remote monitoring of implantable devices interpreted by the Medical Director in this laboratory.

Please list the medical staff that perform post-procedural onsite and longitudinal remote monitoring of implantable devices and their individual volumes. *

	Interpreting Physician	Annual Device Clinic Volumes
Staff # 1
Staff # 2
Staff # 3
Staff # 4
Staff # 5
Staff # 6
Staff # 7
Staff # 8
Staff # 9
Staff # 10

Attach a copy of the laboratory-specific, Device Evaluative Clinic protocol. (Applicable Standard: Part B, 1.11.6B) *

Browse Files
Attach Word, PDF or Excel. Cancel of

Attestation
By signing below, I ({yourName}) attest that the information provided about this facility is accurate and meets the current IAC Cardiac Electrophysiology Standards.
Signature *

Clear
Additional Documentation

Additional case studies and documentation are required. A staff member will contact you regarding additional required documentation and case study submission.
Please verify that you are human *
Hitting "submit" below will send your application to IAC. Please wait until you see a confirmation prior to closing your browser window.
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Cardiac Electrophysiology - Device Clinic