APPLICATION TO PARTICIPATE IN THE NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS

Please read these instructions before completing the application form. Retain the instructions and a copy of the completed application for your records. These instructions will assist you in preparing an accurate and complete application. All questions in this application must be answered in full or the application will be considered incomplete. An incomplete application will be returned and will delay processing. When completing this application, please keep in mind, the more detailed information you can provide, the better. All information received by the NAPBC will remain confidential.

1. Once your application is complete, please select the SUBMIT APPLICATION button at the end of this application.
2. Following completion of the Application you will be prompted to review the Participation Agreement and Business Associate Agreement. Completion of Section V., Information Confirmation, confirms your acceptance of the Participation Agreement and Business Associate Agreement.
3. Your completed application will be reviewed and eligibility will be determined within 30 days of receipt.
4. Please utilize the upload feature in this application. This allows you to include documents available on your computer and eliminates the need to retype this information into the application. However, there is a text box provided, if needed.
5. If you have questions or need help completing this application, please feel free to call or email the NAPBC administrative offices at (312)202-5185 or at NAPBC@facs.org.

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USER INFORMATION

* Your Name (First Last):
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* Your Email:
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