Form Cms-1882 - Portable Xray Survey Report Page 2
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10name of facility
not
standards
code
met
n/a
eXplanatory statement
met
list all portable X-ray equipment (indicate if licensed or registered)
equipment
yes
no
H12
H13
H14
H15
H16
(d) conformity with other federal, state and local laws and
regulations
the supplier of portable X-ray services agrees to render such
services in conformity with federal, state and local laws
relating to safety standards.
h17
§486.102 supervision by a qualified physician
portable X-ray services are provided under the supervision of a
qualified physician.
H18
(a) physician supervision
the performance of the roentgenologic procedures is subject
H19
to the supervision of a physician who meets the requirements
of paragraph (b) of this section and one of the following
requirements is met:
(1) the supervising physician owns the equipment and it is
operated only by his employees, or
(2) The supervising physician certifies annually that he
periodically checks the procedural manuals and observes
the operators’ performance, that he has verified that
equipment and personnel meet applicable federal, state,
and local licensure and registration requirements and that
safe operating procedures are used.
physician’s name
state in which licensed
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form cms-1882 (02/09)
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