CMS-R-263 DMEPOS Site Visit Form

Form Approved
OMB No. 0938-0749
Expires XX/XX

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.

2.

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

 Suite-Office Building
 Office-Warehouse attached

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

Y N
 Attach Photo

3.  Y  N
 Attach Photo

Y
Y
Y
Y

N
N
N
 N  N/A

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

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 60 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, complete and review the information
collection, and record keeping. 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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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) AND/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
 Other - Explain:

 Manager

 Administrator

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

 Attach Copy
13.  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.
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)  Y  N

 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

 Attach Copy

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?

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

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

20.  Y  N
Does the inventory present support the supplier's billing history?
 N/A (No billing history)
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
a) Y  N
b)

Y  N

Does the supplier accept other types of health insurance? If yes, please list:

Does the supplier rent Durable Medical Equipment?
If “Yes”, does the supplier directly service, maintain or replace DME items it
rents to beneficiaries?
Do they have a service contract with another supplier?

 Attach Copy

If “Yes”, please identify the company:
Company Name:
Street Address:
City:
State/Zip:
Telephone #:
(
)

-

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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I ADDITIONAL COMMENTS

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