Form CMS-R-263 DMEPOS Site Visit Form

Site Investigation for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS)
Date Ordered:
Date of First Visit:

Time:

Date of Second Visit:

Time:

REASON FOR VISIT

 Application

 Appeal

 Ad Hoc Request

 Revalidation

 Reactivation

Supplier Type:
Supplier Name:

Authorized Rep:

Supplier Number:

National Provider Identifier (NPI):

Address:

City:

Address 2:

State:

Telephone:

Zip Code:

Please obtain copies of the following documents if checked:

 Business Liability Insurance
 State DME Permit

 Oxygen Permit
 Surety Bond

 Pharmacy License
 Other

If “Other”, explain: ______________________________________________________________________________
FACILITY INFORMATION

1. Type of facility:
 Attach Photo

a.
b.
c.
d.
e.

 Storefront
 Suite-Mall/Plaza
 Suite-Office Building
 Private Residence  Warehouse (Only)
 Office-Warehouse attached
 Other (please describe): _____________________________________________________

What is the approximate size of the facility? ______________________________________________
Is access to facility restricted (gated community, call box, etc)?
Y N
Are there customers or signs of business activity during the inspection?
Y N
Is this facility normally visited by beneficiaries?
Y N
If a home based business, are all local zoning requirements met?
 Y  N  N/A

2.

Y N
 Attach Photo

Is the facility accessible to the disabled?
If no, how does the supplier accommodate disabled persons?
___________________________________________________________________________

3.

Y N
 Attach Photo

Is there a permanent, visible sign with the supplier’s business name posted on the facility?

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 09380749. The time required to complete this information collection is estimated to average 30 minutes per response,
including the time to review instructions, search existing data resources, 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, N2-14-26, Baltimore, Maryland 21244- 1850.

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CMS-R-263 (X/XX)

4.

Y N

Are hours of operation posted?

 Attach Photo

 Open 24/7 (Open 24 hours a day, 7 days a week) OR
 By Appointment Only (no fixed days or hours) OR

Please list hours of operation below:
Monday
Tuesday
Wednesday

5.

Thursday

Friday

Saturday

Sunday

Total Hours:

 Y  N Was the site visit completed? If unable to conduct site visit for any reason (supplier not operational
or inspection refused), please explain in the Additional Comments section at the end of this form.

INTERVIEW OF INDIVIDUAL(S) PRESENT
6. Individual(s) Interviewed:

Last Name:
First Name:

________________________________________
________________________________________

 Owner
 President
 Manager
 Administrator
 Other - Explain:_______________________________________________________________
Additional Information: ____________________________________________________________________
7. The supplier must provide a list of all owners and management with day-to-day control, including name and title.
 Attach Copy

8.  Y  N

Does the supplier have other locations that service Medicare beneficiaries? If additional space is
needed, please use the Additional Comments section at the end of this form.
If yes, please supply the following items:
Business Name:
_______________________________________
Address:
_______________________________________
City:
_______________________________________
State/Zip:
_______________________________________
PTAN:
_______________________________________

9.  Y  N

Does the owner or any relatives own(ed) any other medical entities? If additional space is needed,
please use the Additional Comments section at the end of this form.
If yes, please supply the following items:
Owners Name:
_______________________________________
Relationship:
_______________________________________
Business Name:
_______________________________________
Address:
_______________________________________
City:
_______________________________________
State/Zip:
_______________________________________

10.  Y  N

Does the supplier share office space with other DME suppliers or other medical businesses?
If “Yes”, please supply the following items:
Business Name: __________________________________________________________
Type of business: _________________________________________________________
Owner(s): _______________________________________________________________

Do the co-located businesses share any of the following items?
a.  Y  N
Entrances
b.  Y  N
Office personnel/ownership
c.  Y  N
EIN
d.  Y  N
Telephone
e.  Y  N
Inventory
If yes to any of the above, please describe and attach photos.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

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RECORDS & TELEPHONE

11. Are the patient records maintained (check all that apply)

a)  Y  N
b)  Y  N
c)  Y  N
d)  Y  N
e)  Y  N
 Attach Copy
f)  Y  N
 Attach Copy
g)  Y  N
 Attach Copy

 at this location?
 at an off-site storage facility?
 electronically?

Do these records include physician ordering/referral documentation?
Do these records include beneficiary communications, such as questions received
from beneficiaries and progress notes?
Do these records include documentation of delivery?
Do these records include documentation of maintenance, repairs, or exchanges?
Do these records include proof the supplier provided equipment warranty?

Do these records include proof the supplier advises beneficiaries that they may
either rent or purchase inexpensive or routinely purchased equipment, and of the
capped rental policy?
Do these records include proof the supplier provides beneficiaries with written
information and instructions on how to use Medicare covered items safely and
effectively?

If “No” to any of the above, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12.  Y  N

Does the supplier have a written complaint policy/procedure established and document for
logging complaints? If yes, please attach a copy of their complaint policy and complaint log.

 Attach Copy
13.  Y  N

Does the supplier have a business phone number (other than a cellular phone) listed in a local
telephone directory under the business name?
Please list the phone number: _______________________________________

a)

How was the phone number verified (check all that apply)?

 White/Yellow Pages
b)

 Directory Assistance

Was there telephone activity during the site inspection?

LICENSING/CERTIFICATION

14. Y  N
 Attach Copy

Are the supplier’s business, customers, and employees covered by comprehensive liability
insurance? (Obtain current certificate of insurance with NSC as the certificate holder.)
If “No”, Explain: ___________________________________________________________

15.  Y  N
 Attach Copy

Does the supplier have valid state and federal licenses applicable to their business?
If “No”, Explain: ___________________________________________________________

16.  Y  N

Does the supplier provide custom fitted or fabricated Orthotic and Prosthetic items?
If yes, what are the name(s) and qualifications of those providing this service?
_________________________________________________________________________
_________________________________________________________________________

 Attach Copy

a)  Y  N

Does the supplier fabricate items onsite?

b)  Y  N

If no, does the supplier contract with other companies for the purchase of items
necessary to fill orders? If yes, please identify the company:
Company Name: _________________________________________________________
Street Address: __________________________________________________________
City: ___________________________________________________________________
State/Zip: _______________________________________________________________
Telephone: ______________________________________________________________

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17.  Y  N

Does the supplier provide diabetic footwear?
If yes, what are the name(s) and qualifications of those providing this service?
__________________________________________________________________________
__________________________________________________________________________

 Attach Copy

18.  Y  N

Does the supplier provide oxygen or oxygen related equipment?
If yes, what are the name(s) and qualifications of those providing this service?
__________________________________________________________________________
__________________________________________________________________________

 Attach Copy

INVENTORY

19.

Y N
 Attach Photo

20.

Y N
Does the inventory present support the supplier's billing history?
 N/A – No billing history

Does the supplier have inventory stored on site?
Briefly provide description of inventory present: ___________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

a) If “No”, please obtain invoices and/or contracts to verify the purchase of DME supplies.
 N/A or  Attach Copy
Vendor Name:
Street Address:
City:
State/Zip:
Telephone #:

b)

YN

______________________________________________
______________________________________________
______________________________________________
______________________________________________
(
) __________-_________________________

Does the supplier maintain an off-site storage facility?

If yes, please provide:
Street Address:
City:
State/Zip:
c)

21.

YN

YN

________________________________________________
________________________________________________
________________________________________________

Does the supplier accept other types of health insurance? If yes, please list:
________________________________________________________________________
________________________________________________________________________
Does the supplier rent Durable Medical Equipment?

a)

Y  N

If “Yes”, does the supplier directly service, maintain or replace DME items it
rents to beneficiaries?

b)

Y  N

Do they have a service contract with another supplier?
If “Yes”, please identify the company:
Company Name: ______________________________________
Street Address:
______________________________________
City:
______________________________________
State/Zip:
______________________________________
Telephone #:
(
) ___________-_______________

 Attach Copy

If no to any of the above, please provide an explanation:
______________________________________________________________________________________
______________________________________________________________________________________
CONTACT WITH BENEFICIARY

22. Y  N

Is a copy of the current Supplier Standards provided to all Medicare patients?

23. Y  N

Does the supplier directly solicit (or utilize any third-party vendors to solicit) beneficiary
referrals via telephone? If yes to third-party vendor, list company name(s). If no, please
describe what methods the supplier uses to obtain new customers?

Describe: ___________________________________________________________________

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24.  Y  N
 Attach Copy

25. Y  N

Does the supplier furnish contact information to beneficiaries at the time of delivery?
Example: an equipment sticker label listing the supplier’s name and telephone number
Does the supplier accept returns of substandard (less than full quality for the particular item)
or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or
sold) from beneficiaries? If “No” explain the reasons why:
____________________________________________________________________________
____________________________________________________________________________

SIGNATURE AND DECLARATION

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 dates described therein. 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 of 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 of Site Visit Inspector

____________________________
Date of Inspection

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ADDITIONAL COMMENTS

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