The 2016 CBMD facility accreditation fee is $2,000 for each DXA unit and can be paid either online or by mailing a cheque. This fee, which must be paid in full along with this completed notice of intent, release and registration form, includes the costs of the application review and the initial medical physicist’s visit (but does not include the physicist’s travel costs), as well as processing the CBMD Facility Accreditation application and the CBMD-approved Certificate. Once the notice of intent to participate form (which must be signed by the site contact physician) and application fee have been processed, participants will be given access to the online application. The cost of each anniversary review is $400 and will be paid by the site directly to the CBMD approved medical physicist along with any related disbursements.

CBMD Facility Accreditation is for five (5) years. The price of CBMD Facility Accreditation is subject to change without notice to cover the costs of delivering the CBMD service on a non-profit

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Number of DXA sites:	1 2 3 4 5 6 7 8 x $2000
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Same as Contact Billing Address: Billing Address 2: Billing City: Billing Province: - Select Province/State - CANADA Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon USA Alaska Alabama American Samoa Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Micronesia Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming OTHER Outside Canada / USA Billing Postal Code: Billing Country: - Select Country - Canada USA Name on Card: Card Number: CCV: Exp. Month/Year 01 02 03 04 05 06 07 08 09 10 11 12 / 2425262728293031323334 By clicking on the button below your credit card will be charged $ Cheques should be mailed to the OAR office as follows: Ontario Association of Radiologists CBMD Facility Accreditation Registration 245 Lakeshore Road East Oakville, Ontario L6J 1H9 Note: After paying by cheque your account will remain locked until your payment has been received. The amount on the cheque must be $ per DXA.