Form Cms-10221 - Independent Diagnostic Testing Facilities-Site Investigation Page 3
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5g. peRFoRmance standaRd #9
performance standard #9 requires IDTFs to post these standards for beneficiary review.
1. Has the IDTF posted the standards found at 42 CFR § 410.33 in the IDTF or
Yes
No
home office for a mobile IDTF?
___________________________________________
If no, describe:
h. peRFoRmance standaRd #11
performance standard #11 requires IDTFs to have their diagnostic equipment calibrated and maintained per
manufacturer’s equipment instructions and in compliance with applicable manufacturer’s suggested maintenance
and calibration standards.
1. Does the IDTF have proof that diagnostic equipment has been calibrated
Yes
No
and maintained per equipment instructions in accordance with
manufacturer’s instructions?
___________________________________________
If no, describe:
2. Did the IDTF provide a copy of the maintenance log upon request?
Yes
No
___________________________________________
If no, describe:
I. peRFoRmance standaRd #12
performance standard #12 requires IDTFs to have technical staff on duty with the appropriate credentials to
perform the tests.
1. Can the IDTF furnish the applicable Federal/State licenses and/or
Yes
No
certifications for the individuals performing these services?
___________________________________________
If no, describe:
2. Can technical staff identify the supervising physician(s)?
Yes
No
If yes, list name(s) of supervising physician(s) that was provided by the
_______________________________________________
technician.
___________________________________________
If no, describe:
3. Is the supervising physicians(s) on site?
Yes
No
___________________________________________
If no, describe:
4. Did the IDTF provide a written list of the technician(s) that will be
Yes
No
furnishing services at this IDTF upon request?
___________________________________________
If no, describe:
5. Did the IDTF provide a written list of the supervising physician(s) that will
Yes
No
be supervising services at this IDTF upon request?
___________________________________________
If no, describe:
J. peRFoRmance standaRd #13
performance standard #13 requires IDTFs to have proper medical record storage and be able to retrieve medical
records upon request within 2 business days.
1. Can the IDTF retrieve medical records within 2 business days?
Yes
No
___________________________________________
If no, describe:
2. Does the IDTF have proper medical records storage?
Yes
No
___________________________________________
If no, describe:
3. How are the records stored?
On-site
Electronically
Storage Facility
Other: _______________________
Form CMS-10221 (08/12)
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