Provisional mammographer application (Form R-64)

This form is an application for registration as a Colorado provisional mammographer for performing mammographic examinations under supervision of an ARRT (M) registered mammographer. The registration is for a one (1) year period and may be renewed one (1) time. Renewals must be received thirty (30) days prior to the expiration date. Please refer to 6 CCR 1007-1 Colorado Rules and Regulations Pertaining to Radiation Control Part 2, 2.4.5.4 (3) and Appendix 2M for additional information.

The fee for both the initial application and the renewal is $60. We will provide instructions on how to pay your fee once you submit the form.

If you have trouble filling out this form please contact X-ray Certification Unit at: cdphe.hmxraycomments@state.co.us

General instructions

The Colorado Rules and Regulations pertaining to Radiation Control (Regulations), require any person performing mammographic procedures in the State of Colorado to be adequately trained in accordance with 6 CCR 1007-1, Part 2, 2.4.5.4 (3) and meet the requirements of Appendix 2M.

Until the qualifications in Appendix 2M have been met, a radiologic technologist ARRT registered in radiography should file an application for registration as a provisional mammographer with the department in accordance with 6 CCR 1007-1, Part 2, Appendix 2M, (Part 2): opens in a new tab.

An ARRT registered mammographer does not need to apply for a provisional mammographer registration in the State of Colorado.

After enrollment in, or completion of, a MQSA qualifying 40 hour training program, the radiologic technologist should apply for a one (1) year provisional mammographer registration while preparing to take the ARRT mammography certification exam. You should obtain a provisional mammographer registration prior to performing clinical examinations on patients. This registration may be renewed once.

File the application with the proper attachments. Once we receive the application, we will send you an email with how to pay.

• Please retain a copy of the completed application form for your records.

• Registrations of provisional mammographers are issued in accordance with the requirements contained in the Colorado Rules and Regulations pertaining to Radiation Control, 6 CCR 1007-1, Part 2, 2.4.5.4 (3) and Appendix 2M.

• A current ARRT credential must be submitted at the time of application.

• We will email instructions regarding the payment process after we receive your application. You must submit the application processing fee of $60.00 before this application will be approved.

Contact the X-ray Certification Unit at 303-692-3448 or at cdphe.hmxraycomments@state.co.us with any questions.

Applicant information

Please indicate the type of application you need to submit

Provisional mammographer initial application

Provisional mammographer renewal

Choose your method of payment

I will make the $60.00 payment via online payment portal (credit card or electronic check).

I will mail the $60.00 payment payable to CDPHE XRCU. Paying by check will delay processing due to payment receipt verification.

First name

Last name

Mailing address

City

State

Zip Code

Primary phone number

Indicate type of phone number

Home

Work

Cell

Email address

Please confirm your email

Didactic training (education)

Education program name

Instructor's first name

Instructor's last name

Make sure you complete forty (40) hours or more of documented training to include: breast anatomy and physiology, positioning and compression, quality assurance/quality control techniques, and imaging of patients with breast implants. This course must also meet the requirements for the ARRT Mammography Registry.

Please upload your documentation of didactic training

Documentation of didactic training syllabus and course outline.
Certificates of completion and/or proof of enrollment and course payment.
A copy of your current ARRT credentials.

You can upload up to ten (10) documents below. Be aware that there is a 100 MB size limit for each upload.

Clinical training

It is required that you are directly supervised by a qualified mammographer. The provisional mammographer registration needs be on file at each location you are training at, along with the education requirements, new modality training and current ARRT(R) credentialing.

Clinical facility name (where training is taking place)

Clinical facility address

Clinical facility state

Clinical facility zip

Clinical instructor phone

Clinical instructor name (must have a current “M” credential)

Clinical instructor e-mail

Please confirm email

Applicant attestation

I certify by my signature below, under penalty of law, this application is prepared in conformity with the Colorado Department of Public Health and Environment’s 6CCR 1007-1 Rules and Regulations pertaining to Radiation Control and that all information contained herein, including any attachments is true, accurate and complete to the best of my knowledge and belief. I understand I must be approved as a provisional mammographer before performing mammography procedures in the State of Colorado.

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.

Applicant's signature

Date +