HEALTH A DipndCampUJ August 1, 2017 Region IV U.S. Nuclear Regulatory Commission DNMS/NMSB-B 1600 E. Lamar Boulevard Arlington, TX 76011-4511 Dear State Regulator: N.X; o 2 2011 M DNMS OMS Health Technologies 109 S. Petro Ave. Sioux Falls, SD 57107 701.237.90731800.437.4628 www.dmshealth.com We, DMS Health Technologies, wish to amend our Radioactive Material License number 40-32477-01 to conduct the following: • Add the following physician under condition 12.B.: o Kevin L. Litwin, M.D. for material and use of 35.100 and 35.200. Enclosed is Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01 with Dr. Litwin on as an Authorized User under section 12.B. o Michael E. Farber, M.D. for material and use of 35.100 and 35.200. Enclosed is Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01 with Dr. Farber on as an Authorized User under section 12.B. If you have questions please feel free contact me at 605-357-2612 or e-mail Best Regards, Ma Hennings-Frank, M., CNMT .... ,,v" \ Radiation Safety Officer DMS Health Technologies Enclosed: PUBLIC CJ Immediate Relaaae Release NON-PUBLIC CJ A.3 Sensftfve.Securlty Related CJ A.7 Sensitive Internal CJ Other: • Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01 ll Page lh600377
Transcript
~OMS HEALTH A DipndCampUJ
August 1, 2017
Region IV U.S. Nuclear Regulatory Commission DNMS/NMSB-B 1600 E. Lamar Boulevard Arlington, TX 76011-4511
Dear State Regulator:
~ itCr:I ClJ [f ~ N.X; o 2 2011 M
DNMS
OMS Health Technologies 109 S. Petro Ave.
Sioux Falls, SD 57107 701.237.90731800.437.4628
www.dmshealth.com
We, DMS Health Technologies, wish to amend our Radioactive Material License number 40-32477-01 to conduct the following:
• Add the following physician under condition 12.B.:
o Kevin L. Litwin, M.D. for material and use of 35.100 and 35.200. Enclosed is Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01 with Dr. Litwin on as an Authorized User under section 12.B.
o Michael E. Farber, M.D. for material and use of 35.100 and 35.200. Enclosed is Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01 with Dr. Farber on as an Authorized User under section 12.B.
If you have questions please feel free contact me at 605-357-2612 or e-mail [email protected].
Best Regards,
- ~-i,.-:K. Ma Hennings-Frank, M., CNMT ....,,v" \ Radiation Safety Officer DMS Health Technologies
Enclosed:
PUBLIC CJ Immediate Relaaae ~rmal Release
NON-PUBLIC CJ A.3 Sensftfve.Securlty Related CJ A.7 Sensitive Internal CJ Other:
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• Midwest Division-RBH, LLC d/b/a Belton Regional Medical Center's Radioactive Material license number NRC 24-24405-01
ll Page
lh600377
. '
NRC FORM 374
U.S. NUCLEAR REGULATORY COMMISSION
MATERIALS LICENSE
PAGE 1 OF 3 PAGES
Amendment No. 27
Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, Code of Federal Regulations. Chapter I, Parts 30, 31, 32, 33, 34, 35, 36, 3"/, 39, 40, 70 and 71. and in reliance on statements and representations heretofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special nuclear material designated below; to use such material for the purpose(s) and at the place(s) designated below; to deliver or trans-fer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to all appl!cable rules, regulations, and orders of the Nuclear Regulatory Commission now or hereafter in effect and to any conditions specified below.
Licensee In accordance with letter dated I 4. Expiration Date: April 30, 2021
1. Midwest Division - RBH, LLC November 22, 2016
d/b/a Belton Regional Medical Center +--------------------+-------------~ II
2. 17065 S. 71 Highway Belton, MO 64012
6. Byproduct, source, and/or special nuclear material
A. Any byproduct material permitted by 10 CFR 35.100
8. Any byproduct material permitted by 1 O CFR 35.200
C. Any byproduct material permitted by 1 O CFR 35.300
.,,..
7. Chemical and/or physical form
A. Any
8. Any
C. Any
3. License number: 24-24405-01 is 15. Docket No.: 030-18606 amended in its entirety to read as Reference No.: follows:
8. Maximum amount that licensee may possess at any one time under this license
A. As Needed
8. As Needed
C. 1 curie total
CONDITIONS
9. Authorized use
A. For use in uptake, dilution and excretion studies permitted by 10 CFR 35.100.
8. For use in imaging and localization studies permitted by 10 CFR 35.200.
C. For any use permitted by 10 CFR 35.300.
10. Licensed material may be used or stored at the licensee's facilities located at 17065 South 71 Highway, Belton, Missouri.
11. The Radiation Safety Officer (RSO) for this license is Stephen T. Slack, Ph.D.
..
NRC FORM 374A
MATERIALS LICENSE SUPPLEMENTARY SHEET
U.S. NUCLEAR REGULATORY COMMISSION
License Number
24-24405-01
Amendment No. 27
Docket or Referenc-.e Number 030-18606
12. Licensed material shall only be used by, or under the supervision of:
A. Individuals permitted to work as authorized users in accordance with 10 CFR 35.13 and 10 CFR 35.14.
B. The following individuals are authorized users for the material and medical uses as indicated:
Authorized User
Barry A. Gubin, M.D.
Kevin L. Litwin, M.D.
Graham K. Lee, M.D.
Ryan M. Hegg, M.D.
Michael E. Farber, M.D.
Material and Use
10 CFR 35100, 35.200, and 35.300 (timited to the oral administration of sodium iodide 1-131 in quantities of 33 millicuries or less) 10 CFR 35.100 and 35.200
10 CFR 35.100 and 35.200
1 O CFR 35. 100, 35.200, and 35.300 (limited to the oral administration of sodium iodide 1-131 and parenteral administration of any beta emitter or photon-emitting radionuclide with a photon energy less than 150 keV) 10 CFR 35.100, 35.200, and 35.300 (limited to the oral administration of sodium iodide 1-131 in quantities of 33 millicuries or less)
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NRC FORM 374A
MATERIALS LICENSE SUPPLEMENTARY SHEET
U.S. NUCLEAR REGULATORY COMMISSION
License Number
24-24405-01
Amendment No. 27
Docket or Reference Number
030-18606
PAGE 3 OF 3 PAGES
111- __; II
13. Except as specifically provided otherwise in this license, the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the documents, including any enclosures, listed below. This license condition applies only to those procedures that are required to be submitted in accordance with the regulations. Additionally, this license condition does not limit the licensee's ability to make changes to the radiation protection program as provided for in 1 O CFR 35.26. The U.S. Nuclear Regulatory Commission's regulations shall govern unless the statements, representations, and procedures in the licensee's application and correspondence are more restrictive than the regulations.
A. Application dated November 9, 2010(ML103200238)
B. Letter dated September 7, 2011 (ML 112770033)
C. Letter dated February 23, 2012(ML120590103)
D. Letter dated June 20, 2012(ML12194A301}
E. Letter dated October 18, 2012(ML12292A287)
F. Letter dated October 29, 2015(ML15313A520)
G. Letter dated July 25, 2016(ML16208A310)
Date: February 21, 2017
FOR THE U.S. NUCLEAR REGULATORY COMMISSION
By ?4aAA, !l ~ Sara A. Forster, M.S. Materials Licensing Branch Region Ill
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NRC FORM532 U.S. NUCLEAR REGULATORY COMMISSION (05-2016) a»-•llhfl<.t l¥\ \ . !?j ACKNOWLEDGEMENT - RECEIPT OF CORRESPONDENCE
.,. ........
Name and Address of Applicant and/or Licensee Date
I 08/08/2017
' License Number{s)
Ms. Mary Hennings-Frank I 40-32477-01 I Corporate Radiation Safety Officer
Mail Control Number{s} DMS Health Technologies 109 South Petro Avenue I 600377 I Sioux Falls, SD 57107 Licensing and/or Technical Reviewer or Branch
C. Hill, Licensing Assistant
This is to acknowledge receipt of your: 0 Letter and/or D Application Dated: 08/01/2017
The initial processing, which included an administrative review, has been performed.
0 Amendment D Termination D New License D Renewal
D There were no administrative omissions identified during our initial review.
D This is to acknowledge receipt of your application for renewal of the material{s) license identified above. Your application Is deemed timely filed, and accordingly, the license will not expire until final action has been taken by this office.
D Your application for a new NRC license did not include your taxpayer identification number. Please complete and submit NRC Form 531, Request for Taxpayer Identification Number, located at the following link: httg;//www.nrc.gov/reftding-rm/doc-collections/forms/nrc531.gdf
Follow the instructions on the form for submission.
D The following administrative omissions have been Identified:
Your application has been assigned the above listed MAIL CONTROL NUMBER. When calling to inquire about this action, please refer to this control number. Your application has been forwarded to a technical reviewer. Please note that the technical review, which is normally completed within 180 days for a renewal application (90 days for all other requests), may identify additional omissions or require additional information. If you have any questions concerning the processing of your application, our contact information is listed below:
Region IV U. S. Nuclear Regulatory Commission DNMS/NMSB - B 1600 E. Lamar Boulevard Arlington, TX 76011-4511 (817) 200-1209 or (817) 200-1140
NRC FORM 532 (05-2016)
BETWEEN:
Accounts Receivable/Payable and
Regional Licensing Branches
______ , ________ . __ _
[ FOR ARPB USE ] INFORMATION FROM WBL --··· · · · -···· -- · · --- --- -- ·- --- -·
Program Code: 02220 Status Code: Pending Amendment Fee Category:7C Exp. Date: 04/30/2022 Fee Comments: Decom Fin Assur Reqd: N
License Fee Worksheet - License Fee Transmittal A. REGION
1. APPLICATION ATTACHED Applicant/Licensee: DMS Health Technologies
Received Date: 08/02/2017 Docket Number: 3036404 Mail Control Number: 600377 License Number: 40-32477-01
Action Type: Amendment
2. FEE ATTACHED
Amount:
Check No.: + 3. COMMENTS
Signed: t~~1 ¢/~-Date: ~/r5/17
B. LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered I I
1. Fee Category and Amount: --------------------------------~
2. Correct Fee Paid. Application may be processed for:
