Form CMS-1880 Request for Certification as Supplier of Portable Xray E

REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE X-RAY SERVICES

UNDER THE MEDICARE/MEDICAID PROGRAM

(Please read the following instructions before completing this form)

FORM APPROVED

OMB No. 0938-0027

Identifying
Information

(S7)

(S14)

MEDICAID

2. PH.D/SC.D.

1. PHYSICIAN

■
BOTH

(a) BS/BA IN RADIOLOGIC TECHNOLOGY

■ INDIVIDUAL
■ PARTNERSHIP

■
■

CITY, COUNTY, AND STATE

NAME OF SUPPLIER

■

(S15)

(S22)

■

5. OTHER

ZIP CODE

STREET ADDRESS

OTHER THAN PRIVATE (Specify) _______________________

CORPORATION

4. B.S./B.A.

3. M.S./M.A.

(S1)

STATE/COUNTY

(S16)

(S17)

(b) ASSOCIATE DEGREE
(c) GRADUATE OF 24 MO.
(d) ALL OTHER (Specify)
RADIOLOGIC TECHNOLOGY
APPROVED SCHOOL OF
RADIOLOGIC TECHNOLOGY

■
■

■
■

MEDICARE/MEDICAID PROVIDER NUMBER

(S2)

(Including area code)

TELEPHONE NUMBER

STATE REGION

Form CMS-1880 (10-80)

I further understand that a violation of such laws will constitute grounds for withdrawal of approval under the regulations.
SIGNATURE OF AUTHORIZED OFFICIAL
TITLE

DATE

I certify that this application is true, correct, and complete. I agree, if approval is granted, to render portable X-ray services in conformity with Federal, State, and local laws relating to safety standards.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is
0938-0027. The time required to complete this information collection is estimated to average 15 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.

Number of
Technologists
(Full time equivalents)

IV.

(Check one)

III.
Type of Ownership
or Control

(Check one)

II.
Qualifications of
Director

I.

■ MEDICARE

REQUEST TO ESTABLISH ELIGIBILITY IN

(S20)

(S18)

(S6)

(S3)

Completion of the Request at Resurvey — At the time of resurvey, the surveyor will bring this form and either, request that a facility representative complete, sign, date and return it at the completion of the onsite visit (at
which time the surveyor will review it for completeness and accuracy); or the surveyor may complete the form and have the facility representative review and sign it. In either case, the surveyor will initial after the facility
representative's signature.

Question IV — Include only those persons regularly employed. Do not include director. Count each technologist only once; e.g., technologist holds a B.S. degree in radiologic technology and is also a graduate of a 24-month
approved school, place his full-time equivalents in block A. To determine full-time equivalents, divide the total number of hours worked by all employees in each classification in the week prior to the week of filing the
request by the number of hours in the standard work week. If the result for each classification is not a whole number, express it as a quarter fraction; e.g., .00, .25, .50, or .75.

Question II — The director is the owner or person having administrative control and responsibility for the operation of portable X-ray equipment. If more than one degree is held, check the highest degree; e.g., director holds
both an M.D. and an M.P.H., check physician; director holds Ph.D. and M.S., check Ph.D. Check block 1 if a physician is licensed to practice medicine and osteopathy.

State/County Code and State Region — Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete.

Medicare/Medicaid Provider Number — Leave blank on all initial certifications. On all recertifications, insert the supplier's assigned six-digit provider number.

Detailed instructions are given below for questions other than those considered self-explanatory.

Answer all questions as of the current date. Return the original and first two copies to the State agency in the envelope provided, retain the last copy for your files. If a return envelope is not provided, the name and address of
the State agency may be obtained from the nearest Social Security office.

Submission of this form will initiate the process of obtaining a decision as to whether the conditions of coverage are met. Do not delay returning the form even though certain information is not now available. Assistance in
completing the form is available from the State agency.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES