department of HealtH and Human services centers for medicare & medicaid services form approved omb no. 0938-0027 provider number date surveyed portable x-ray survey report name of supplier name of surveyor H1 address of supplier WH2 i (1) initial survey (2) resurvey professional qualifications of surveyor code h5 standards §486.100 compliance with federal, state, and local laws and regulations the supplier of portable X-ray services is in conformity with all applicable federal, state, and local laws and regulations. (a) licensure or registration of supplier in any state in which state or applicable local law provides for the licensure or registration of suppliers of X-ray services, the supplier is (1) licensed or registered pursuant to such law, or (2) approved by the agency of the state or locality responsible for licensure or registration as meeting the standards established for such licensure or registration. licensed name of agency: approved for licensure n/a met not n/a met eXplanatory statement H6 H7 (b) licensure or registration of personnel all personnel engaged in operating portable X-ray equipment are currently licensed or registered in accordance with all applicable state and local laws. no. of personnel no. licensed or approved no. not licensed or approved (c) licensure or registration of equipment all portable X-ray equipment used in providing portable X-ray services is licensed or registered in accordance with all applicable state and local laws. name of licensing agency H8 H9 H10 H11 form cms-1882 (02/09) page 1 American LegalNet, Inc. www.FormsWorkFlow.com name of facility code standards list all portable X-ray equipment (indicate if licensed or registered) equipment yes no met not n/a met eXplanatory statement H12 H13 H14 H15 H16 (d) conformity with other federal, state and local laws and regulations the supplier of portable X-ray services agrees to render such services in conformity with federal, state and local laws relating to safety standards. §486.102 supervision by a qualified physician portable X-ray services are provided under the supervision of a qualifiedphysician. (a) physician supervision the performance of the roentgenologic procedures is subject to the supervision of a physician who meets the requirements of paragraph (b) of this section and one of the following requirements is met: (1) the supervising physician owns the equipment and it is operated only by his employees, or (2)Thesupervisingphysiciancertifiesannuallythathe periodically checks the procedural manuals and observes theoperators'performance,thathehasverifiedthat equipment and personnel meet applicable federal, state, and local licensure and registration requirements and that safe operating procedures are used. h17 H18 H19 physician's name form cms-1882 (02/09) state in which licensed 2 American LegalNet, Inc. www.FormsWorkFlow.com name of facility code standards (b) qualifications of the physician supervisor portable X-ray services are provided under the supervision of a licensed doctor of medicine or licensed doctor of osteopathy whoisqualifiedbyadvancedtrainingandexperienceinthe use of X-rays for diagnostic purposes, i.e., he (1)iscertifiedinradiologybytheAmericanBoardofRadiology or by the american osteopathic board of radiology or possessesqualificationswhichareequivalenttothose requiredforsuchcertification,or (2)iscertifiedormeetstherequirementsforcertificationina medicalspecialtyinwhichhehasbecomequalifiedby experienceandtrainingintheuseofX-raysfordiagnostic purposes, or (3) specializes in radiology and is recognized by the medical community as a specialist in radiology. name of board date Certification Certified no. met not n/a met eXplanatory statement specialization OtherQualifications(specify) h20 §486.104 qualifications, orientation, and health of technical personnel (405.1413) PortableX-rayservicesareprovidedbyqualifiedtechnologists. (a) qualifications of technologists all operators of the portable X-ray equipment meet the requirements of paragraph (a)(1), (2), (3), or (4) of this section: (1) successful completion of a program of formal training inx-raytechnologyinaschoolapprovedbytheJoin review committee on education in radiologic technology (JRCERT),orhaveearnedabachelor'sorassociatedegree in radiologic technology from an accredited college or university H21 form cms-1882 (02/09) American LegalNet, Inc. www.FormsWorkFlow.com 3 name of facility code standards (2) for those whose training was completed prior to July1,1966,butonorafterJuly1,1960:Successful completionof24fullmonthsoftrainingand/orexperience underthedirectsupervisionofaphysicianwhoiscertified in radiology by the american board of radiology or who possessesqualificationswhichareequivalenttothose requiredforsuchcertification,andatleast12fullmonthsof pertinentportableX-rayequipmentoperationexperiencein the5yearspriortoJanuary1,1968. (3) for those whose training was completed prior to July1,1960:Successfulcompletionof24fullmonthsof trainingand/orexperienceofwhichatleast12fullmonths were under the direct supervision of a physician who is certifiedinradiologybytheAmericanBoardofRadiologyor whopossessesqualificationswhichareequivalenttothose requiredforsuchcertification,andatleast12fullmonthsof pertinentportableX-rayequipmentoperationexperiencein the5yearspriortoJanuary1,1968. (4) for those whose training was completed prior to January1,1993,successfulcompletionofaprogramof formal training in X-ray technology in a school approved by the council on education of the american medical association, or by the american osteopathic association is acceptable. H22 H23 no. of technologists meeting: 1.___ 2.___ 3.___ license required? yes no met not n/a met eXplanatory statement (b) personnel orientation the supplier of portable X-ray services has an orientation program for personnel based on a procedural manual which is: available to all members of the staff, incorporates relevant portions of professionally recognized documents, and includes instruction in all of the following: (1) precautions to be followed to protect the patient from unnecessaryexposuretoradiation; (2) precautions to be followed to protect an individual supporting the patient during X-ray procedures from unnecessaryexposuretoradiation; H24 H25 form cms-1882 (02/09) American LegalNet, Inc. www.FormsWorkFlow.com 4 name of facility code H26 standards (3) precautions to be followed to protect other individuals in thesurroundingenvironmentfromexposuretoradiat