Form Cms-1882 - Portable Xray Survey Report
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10W
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department of HealtH and Human ser vices
form approved
centers for medicare & medicaid ser vices
omb no. 0938-0027
provider number
date surveyed
initial
(1)
(2)
resurvey
port able x-ra y survey report
survey
H1
H2
name of supplier
address of supplier
name of surveyor
professional qualifications of surveyor
met not
code
standards
n/a
eXplanatory statement
met
§486.100 compliance with federal, state, and local
h5
laws and regulations
the supplier of portable X-ray services is in conformity with all
applicable federal, state, and local laws and regulations.
H6
(a) licensure or registration of supplier
in any state in which state or applicable local law provides for
the licensure or registration of suppliers of X-ray services, the
supplier is (1) licensed or registered pursuant to such law,
or (2) approved by the agency of the state or locality
responsible for licensure or registration as meeting the
standards established for such licensure or registration.
licensed
approved for licensure
n/a
name of agency:
H7
(b) licensure or registration of personnel
all personnel engaged in operating portable X-ray equipment
are currently licensed or registered in accordance with all
applicable state and local laws.
no. of personnel
H8
no. licensed or approved
name of licensing agency
H9
no. not licensed or approved
H10
H11
(c) licensure or registration of equipment
all portable X-ray equipment used in providing portable X-ray
services is licensed or registered in accordance with all
applicable state and local laws.
page 1
form cms-1882 (02/09)
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