Information Collection

Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs)

IC 181196 under ICR 202306-0938-004 · OMB 0938-1029.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10221 Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs)	Form and Instruction
CMS-10221 Site Investigation for Independent Diagnostic Testing Fa CMS-10221 - IDTF Site Investifgation Form (1).pdf	Form and Instruction
CMS-10221 Site Investigation for Independent Diagnostic Testing Fa CMS-10221 - IDTFs Instrument rev.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 410.33

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10221	Site Investigation for Independent Diagnostic Testing Facilities Application	CMS-10221 - IDTFs Instrument rev.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Provider Enrollment, Chain and Ownership System (PECOS) number 09-70-0532

FR Citation: 87 FR 19177

Number of Respondents: 652

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	652	-75	727
Annual IC Time Burden (Hours)	1,304	-150	1,454
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.