Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) (CMS-10221)

OMB 0938-1029

The Independent Diagnostic Testing Facilities (IDTF) - Site Investigation form was developed and implemented to allow for CMS to have a standard format to collect and verify information regarding the compliance of independent diagnostic testing facilities (IDTFs) with the performance standards found in 42 CFR 410.33(g). CMS is now seeking re-instatement of the use of this form.

The latest form for Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) (CMS-10221) expires 2023-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10221 Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) Form and Instruction
CMS-10221 - Supporting Statement --.docx Supporting Statement A
Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) Form and Instruction

All Historical Document Collections

202306-0938-004 Approved with change	Reinstatement without change of a previously approved collection	2023-06-07
202001-0938-003 Approved without change	Reinstatement without change of a previously approved collection	2020-01-10
201509-0938-005 Approved with change	Reinstatement with change of a previously approved collection	2015-09-11
201206-0938-004 Approved without change	Reinstatement without change of a previously approved collection	2012-06-25
200707-0938-005 Approved without change	New collection (Request for a new OMB Control Number)	2007-07-13