Form Cms-10221 - Independent Diagnostic Testing Facilities-Site Investigation Page 5
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54. addItIonal questIons FoR InspectoR
A. Was the inspector able to complete the site visit?
Yes
No
___________________________________________
If no, describe:
b. Additional Comments (if none, please check N/A)
N/A
C. beyond what is disclosed in this site visit worksheet, was there any
Yes
No
evidence obtained during the site visit that could indicate that the
supplier is not in compliance with the provisions in 42 CFR 410.33?
__________________________________________
If yes, describe:
D. Photographs Required
Photograph exterior of building (including business sign & hours of operation if possible)
Photograph interior facility entrance if located within a a multiple tenant building (business signs & hours
of operation, if possible)
E. Inspector’s Information and Signature
I prepared this document, which is the report of my inspection of the noted facility pursuant to their
enrollment in the Medicare program. This report is a true and accurate account of the events that occurred
and transpired on the date(s) reported herein that this site visit was performed. I am capable and willing
to testify as a witness at a hearing about the content of this report. The foregoing information is based on
my personal knowledge or is information provided to me in my official capacity. I declare under penalty or
perjury that this information is true and correct to the best of my knowledge and belief.
Executed this _____ day of ________________________, 20_____
Signature of Declarant
Printed Name
Organization
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMb control number. The valid OMb control number for this information collection is 0938-1029. The time required to complete this
information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data resources,
and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, baltimore, Maryland 21244-1850.
Form CMS-10221 (08/12)
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