Form Cms-10221 - Independent Diagnostic Testing Facilities-Site Investigation Page 2
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5B. peRFoRmance standaRd #4
performance standard #4 requires IDTFs to have all applicable diagnostic testing equipment available at the
physical site (excluding portable diagnostic testing equipment).
1. Does the IDTF maintain a catalog of portable diagnostic equipment,
Yes
No
N/A
including diagnostic testing equipment serial/registration numbers, at the
physical site?
___________________________________________
If no, describe:
2. Did the IDTF make the portable equipment or mobile unit(s) available for
Yes
No
N/A
inspection?
___________________________________________
If no, describe:
3. Does the IDTF maintain a current inventory of diagnostic equipment,
Yes
No
including diagnostic testing equipment serial/registration numbers?
___________________________________________
If no, describe:
4. Has the IDTF provided updates to the MACs regarding equipment changes
Yes
No
in accordance with existing regulation?
___________________________________________
If no, describe:
c. peRFoRmance standaRd #5
performance standard #5 requires IDTFs to maintain a primary business phone under the name of the business.
1. Is the business telephone located at the IDTF or within the home office
Yes
No
for the mobile IDTF?
___________________________________________
If no, describe:
2. Is the business telephone number listed in local telephone directory or
Yes
No
is it available through directory assistance?
___________________________________________
If no, describe:
d. peRFoRmance standaRd #6
performance standard #6 requires IDTFs to have comprehensive liability insurance in the amount $300,000 per
facility.
1. Did the IDTF provide proof of insurance upon request?
Yes
No
___________________________________________
If no, describe:
e. peRFoRmance standaRd #7
performance standard #7 states that IDTFs must agree not to directly solicit patients; this includes, but is not
limited to, a prohibition on telephone, computer, or in-person contacts.
How does the IDTF solicit new business? Describe:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
F. peRFoRmance standaRd #8
performance standard #8 requires IDTFs to maintain a protocol regarding beneficiaries’ complaints.
1. Does the supplier have a written complaint resolution procedure
Yes
No
established?
___________________________________________
If no, describe:
Form CMS-10221 (08/12)
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