OMB control number
Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) (CMS-10221)
OMB 0938-1029 · HHS/CMS.
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 2027-01-31 and is listed under ICR 202306-0938-004.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 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All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202306-0938-004 | Reinstatement without change of a previously approved collection | 2023-06-07 | Approved with change | |
| 202001-0938-003 | Reinstatement without change of a previously approved collection | 2020-01-10 | Approved without change | |
| 201509-0938-005 | Reinstatement with change of a previously approved collection | 2015-09-11 | Approved with change | |
| 201206-0938-004 | Reinstatement without change of a previously approved collection | 2012-06-25 | Approved without change | |
| 200707-0938-005 | New collection (Request for a new OMB Control Number) | 2007-07-13 | Approved without change |