(CMS-1880) Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

OMB 0938-0027

The Medicare program requires portable X-ray suppliers to be surveyed for health and safety standards. The CMS-1880 is used by the surveyor to determine if a portable X-ray applicant meets the eligibility requirements.

The latest form for (CMS-1880) Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form expires 2021-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction
Supporting Statement A for CMS-1880 04.20.21.docx Supporting Statement A
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction

All Historical Document Collections

202108-0938-004 Approved without change	Revision of a currently approved collection	2021-08-13
201803-0938-010 Approved with change	Revision of a currently approved collection	2018-03-28
201502-0938-001 Approved without change	Extension without change of a currently approved collection	2015-02-04
201405-0938-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-05-13
201203-0938-006 Approved without change	Extension without change of a currently approved collection	2012-03-13
200902-0938-008 Approved without change	Extension without change of a currently approved collection	2009-02-13
200512-0938-006 Approved without change	Extension without change of a currently approved collection	2005-12-16
200207-0938-001 Approved without change	Extension without change of a currently approved collection	2002-07-03
199907-0938-001 Approved without change	Reinstatement without change of a previously approved collection	1999-07-01
199603-0938-002 Approved without change	Reinstatement with change of a previously approved collection	1996-03-19
199111-0938-003 Approved without change	Reinstatement with change of a previously approved collection	1991-11-27
198907-0938-003 Approved without change	Extension without change of a currently approved collection	1989-07-05
198605-0938-011 Approved without change	Revision of a currently approved collection	1986-05-19
198405-0938-011 Approved without change	Reinstatement with change of a previously approved collection	1984-05-24
198212-0938-006 Disapproved and continue	Revision of a currently approved collection	1982-12-23
198204-0938-008 Approved without change	Reinstatement with change of a previously approved collection	1982-04-02
198107-0938-020 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-28
198102-0938-017 Approved without change	Reinstatement with change of a previously approved collection	1981-02-27
198006-0938-004 Approved without change	Reinstatement with change of a previously approved collection	1980-06-09
197803-0938-018 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-03-29
197710-0938-008 Approved without change	Revision of a currently approved collection	1977-10-03
197709-0938-005 Not subject to PRA and continue	Revision of a currently approved collection	1977-09-13
197412-0938-005 Approved without change	Revision of a currently approved collection	1974-12-16