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Policy for Self Requesting Mammogram



Facilities in North Carolina that offer screening mammography may not accept self-referred patients because a doctor is not involved.  However under 15A NCAC 11.0603 (a)(1)(G), they may accept self-requesting patients.  Facilities who accept self requesting patients, the inspectors will be reviewing the policy.  This policy shall document the actions of the facility for self-requesting patients, following the patient from point of contact to the end of the mammography procedure.  It is required that the listing of the doctor who will accept self requesting patients be available.  A mechanism shall be in place for updating that list and this should be explained to the inspector. 

As for facilities that do not accept self-requesting mammograms, they MUST have a policy in place stating that fact.

Many facilities have chosen to offer screening mammography on a self-requesting basis.  These facilities are expected to have a policy that outlines how such patients would be  accepted.  The policy shall address the following situations:

a.  The self-requesting patient must provide the facility with the name of a referring physician who is willing to provide approprite follow-up care.  This information shall be confirmed by the facility accepting it.

b.  A facility accepting self-requesting patients shall maintain a list of physician(s) who will accept the self-requestion patient for follow-up care.  Either the patient or the facility may select the physician for follow-up care.  The selected physician, by agreeing to be on the list, is responsible for the appropriate follow-up and treatment protocols.


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