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Approval of Physicians to Use or Prescribe Radioactive Materials for
Diagnosis and/or Therapy

Application Checklist (Should link to attachment file)


Appendix A – Training Requirements and Certifying Organizations (Should link to attachment file)
Appendix B – City of NY Application for Radioactive Materials License Supplement I (Should link to attachment file)
Appendix B – City of NY Application for Radioactive Materials License Supplement II (Should link to attachment file)

Purpose:  To promulgate procedures for evaluating the credentials of physicians who wish to use or prescribe radioactive materials for diagnosis and/or therapy.

Policy:   Authorized users involved in the medical use of radioactive materials have the following special responsibilities:

  1. Examination of a patient and medical records to determine if a radiation procedure is appropriate,
  2. Prescription of  the radiation dose and how it is to be administered,
  3. Actual use of, or direction of other paramedical personnel in the use of radioactive materials; and
  4. Interpretation results of diagnostic procedures and evaluation results of therapy procedures.

Any physician who intends to use or prescribe the use of radioactive materials for diagnosis or therapy must be approved by the Joint Radiation Safety Committee as an Authorized User.

Scope:  this policy applies to physicians performing activities covered by radioactive materials licenses issued to and administered by the Columbia University Radiation Safety Office.  The following facilities are covered by such licenses:

  1.  New York-Presbyterian Hospital, including Milstein Hospital, Allen Hospital, and Children’s Hospital of New York (license 75-2878-01)
  2. Gamma Knife Suite (license 93-2878-05)

References:

  1. New York City Health Code, Article 175.06, Professional Practitioners and Related Provisions
  2. New York City Health Code, Article 175.103, Medical Use of Radioactive Materials
  3. City of New York Department of Health, Bureau of Radiological Health, License Guide 10.8 Rev 2, Guide for Preparations of Application for Medical Programs
  4. New York City Department of Health Radioactive Materials License 75-2878-01
  5. New York City Department of Health Radioactive Materials License 93-2878-05

Procedures:

  1. Physicians may be approved as authorized users for one or more of the following methods
    • Uptake, dilution, or excretion studies
    • Imaging and localization studies
    • Therapeutic use of radiopharmaceuticals or radiobiologics
    • Therapeutic use of brachytherapy sources
    • Ophthalmic use of strontium-90
    • Sealed sources for diagnosis
    • Teletherapy
  2. Specific training requirements for each are found in Appendix A
  3. The following documents to the chairman of the Joint Radiation Safety Committee:
    • Letter from department chairman or physician in charge requesting specific privileges
    • Current New York State medical license
    • Curriculum vitae
  4. Physicians who are board certified in an appropriate medical discipline must submit documentation of certification.  See Appendix A for list of approved certifying organizations.  Application Supplement I (Appendix B) with items 1, 2, 3, and 6 completed must also be submitted.  A physician certified as British “Fellow of the Faculty of Radiology” (FFR) or “Fellow of the Royal College of Radiology” (FRCR) should submit a copy of the certificate and evidence of specialization. 
  5. If a physician has been previously authorized for medical use and wants to use only material permitted by a previous license issued by New York City Health Department Bureau of Radiological Health, agreement state, or U.S. Nuclear Regulatory Commission, submit a copy of the license on which the physician was specifically named as an authorized user.  Application Supplement I (Appendix B) with items 1, 2, 3, and 6 completed must also be submitted.
  6. Physicians not previously authorized by New York City Health Department Bureau of Radiological Health or other licensing agency and not board certified must submit a complete description of their training and experience using Application Supplements I and II (Appendix B).  Note:  please ensure that Section 3 of Supplement II (Preceptor Statement) is accurately and completely filled in by the preceptor. 
  7. The Chief Radiation Safety Officer shall review the application materials submitted and make recommendation to the Chairman of the Joint Radiation Safety Committee regarding approval of the application.  Interim approval may be granted based on the materials submitted.  The Chair will submit the physician’s credentials to the Joint Radiation Safety Committee for final approval.

August, 2011