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 can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
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Form and Instruction |
Supporting Statement A |
Form CMS-10221 Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs)
CMS-10221 - Supporting Statement --.docx
Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) All Historical Document Collections
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Approved with change |
Reinstatement without change of a previously approved collection | 2023-06-07 | |
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Approved without change |
Reinstatement without change of a previously approved collection | 2020-01-10 | |
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Approved with change |
Reinstatement with change of a previously approved collection | 2015-09-11 | |
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Approved without change |
Reinstatement without change of a previously approved collection | 2012-06-25 | |
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Approved without change |
New collection (Request for a new OMB Control Number) | 2007-07-13 |