Form Cms-10221 - Independent Diagnostic Testing Facilities-Site Investigation
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5DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMb No. 0938-1029
Independent dIagnostIc testIng FacIlItIes—sIte InvestIgatIon
42 cFR § 410.33
Date Ordered: _________________________
Date of First Visit: ______________________
Time: ______________________
Date of Second Visit: ______________________
Time: ______________________
1. Reason FoR vIsIt
Initial/Change
Revalidation
Hearing & Appeal
Ad Hoc
2. FacIlIty InFoRmatIon
Facility Name
National Provider Identifier (NPI)
Name of Authorized Representative(s) or Interviewee(s)
Name of Authorized Representative(s) or Interviewee(s)
Name of Authorized Representative(s) or Interviewee(s)
Name of Authorized Representative(s) or Interviewee(s)
Practice Location (Physical Street Address)
City
State
Zip Code
business Telephone Number
3. FacIlIty InspectIon
a. peRFoRmance standaRd #3
performance standard #3 requires IDTFs to maintain a physical facility on an appropriate site.
(photogRaph RequIRed)
Office Suite-Mall
Office Suite-Office building
Private Residence
Warehouse
Other. Please describe: _____________________________
1. Is the ITDF located on an appropriate site?
Yes
No
___________________________________________
If no, describe:
2. Is the IDTF handicap accessible?
Yes
No
___________________________________________
If no, describe:
3. Were there patients in the facility during the inspection?
Yes
No
___________________________________________
If no, describe:
4. If this IDTF is at a fixed location, does the facility contain adequate space
Yes
No
N/A
for testing, including all tests listed on the enrollment application, facilities
for hand washing, adequate patient privacy accommodations, and storage
of business and medical records?
___________________________________________
If no, describe:
5. If this IDTF is a mobile facility, does the mobile unit have access to facilities
Yes
No
N/A
for hand washing, adequate patient privacy accommodations, and a home
office location for the storage of business and medical records?
___________________________________________
If no, describe:
Form CMS-10221 (08/12)
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