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pdfForm Approved
OMB No. 0938-0749
Expires: XX/XXXX
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Site investigation for suppliers of Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS)
Date ordered (mm/dd/yyyy)
Date of frst visit (mm/dd/yyyy)
Time
Date of second visit (mm/dd/yyyy)
Time
Reason for visit
Application
Appeal
Non-application based
Revalidation
Reactivation
Supplier type
Supplier name
Authorized rep
Supplier number
National Provider Identifer (NPI)
Address
City
Address 2
State
ZIP code
Phone
Was the site visit completed? ..........................................................................................................................................
If unable to conduct site visit for any reason (supplier not operational or inspection refused), explain in the
Additional Comments section at the end of this form.
For non-application based requests, attach copies of the following documents if checked:
Oxygen permit
Pharmacy license
State DME permit
Business liability insurance
Other, explain:
Yes
No
Surety bond
Paperwork Reduction Act: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0749. The time required to complete this information collection is estimated to average 30 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.
Form CMS-R-263 (XX/XX)
1
Facility information
1. Type of facility:
Attach photo
Storefront
Suite-mall/Plaza
Suite-offce building
Offce-warehouse attached
Other, describe:
Private residence
Warehouse (only)
a. What is the approximate size of the facility? (42 CFR 424.57(c)(7))
Yes
No
c. Are there customers or signs of business activity during the inspection? ..................................................................
Yes
No
d. Is this facility normally visited by benefciaries? ..........................................................................................................
Yes
No
2. Is the facility accessible to the disabled? (42 CFR 424.57(c)(1)) ................................................................................
Attach photo
Yes
No
Yes
No
Yes
No
b. Is access to facility restricted (gated community, call box, etc.)? (42 CFR 424.57(c)(7)) .............................................
If yes, explain how access is granted:
3. Is there a permanent, visible sign with the supplier’s business name posted on the facility?
(42 CFR 424.57(c)(7)) .........................................................................................................................................................
Attach photo
If no, explain:
4. Are hours of operation posted? (42 CFR 424.57(c)(7))...............................................................................................
Attach photo
If yes, where are hours of operation posted?
Main entrance of building
Entrance of supplier
Both
Identify the facility’s hours of operations:
Open 24/7 (Open 24 hours a day, 7 days a week)
By appointment only (no fxed days or hours)
List hours of operation below:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
5. Does the supplier share office space with other DME suppliers or other medical businesses?
(42 CFR 424.57(c)(29)) ......................................................................................................................................................
If yes, supply the following items:
Total Hours:
Yes
No
Business name
Type of business
Owner(s)
6. Do the co-located businesses share any of the following items? (42 CFR 424.57(c)(29)) (check all that apply)
Entrances
Patient exam rooms
Inventory
If checked, describe and attach photos:
Form CMS-R-263 (XX/XX)
2
Interview or individual(s) present
7. Individual(s) interviewed
Last name
Owner
President
Additional Information
First name
Manager
Administrator
Other, explain:
8. Does the supplier have other locations that service Medicare benefciaries? (42 CFR 424.57(c)(17)) .....................
Yes
No
Yes
No
If yes, supply the following items. If additional space is needed, use the Comments section below.
Business name
Address
City
State
ZIP code
PTAN
Comments
9. Does the owner or any relatives own(ed) any other medical entities? (42 CFR 424.57(c)(17)) ...............................
If yes, supply the following items. If additional space is needed, use the Comments section below.
Owners name
Relationship
Business name
Address
City
State
ZIP code
Comments
Form CMS-R-263 (XX/XX)
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Licensing/certification
10. For non-application based requests, are the supplier’s business, customers, and employees covered by comprehensive
liability insurance? (Obtain current certificate of insurance with the NPE as the certificate holder.)
(42 CFR 424.57(c)(10)) .......................................................................................................... Yes
No
N/A application based
Attach copy
If no, explain:
11. For non-application based requests, does the supplier have valid state and federal licenses applicable to their business?
(42 CFR 424.57(c)(1)) ............................................................................................................ Yes
No
N/A application based
Attach copy
If no, explain:
12. Does the supplier provide custom ftted or fabricated Orthotic and Prosthetic items?.........................................
If yes, what are the name(s) and qualifcations of those providing this service?
Yes
No
a. Does the supplier fabricate or custom fit items onsite? (42 CFR 424.57(c)(4))........................................................
Yes
No
b. If no, does the supplier contract with other companies for the purchase of items necessary to fll orders? ..........
Yes
No
Yes
No
Yes
No
c. If yes, identify the company:
Company name
Phone
Street address
City
State
ZIP code
13. Does the supplier provide diabetic footwear? ........................................................................................................
Attach copy
If yes, what are the name(s) and qualifcations of those providing this service?
14. Does the supplier provide oxygen or oxygen related equipment? (42 CFR 424.57(c)(27)) ..................................
Attach copy
If yes, what are the name(s) and qualifcations of those providing this service?
Form CMS-R-263 (XX/XX)
4
Inventory
15. Does the supplier have inventory stored on site? (42 CFR 424.57(c)(4)) ...............................................................
Attach copy
Yes
No
If yes, briefy provide description of inventory present:
If no, briefy describe why:
16. Does the supplier maintain an off-site storage facility? (42 CFR 424.57(c)(4)).........
If yes, provide the following:
Yes
No
N/A application based
Street address
City
State
17. Does the supplier accept other types of health insurance?.......................................
ZIP code
Yes
No
N/A application based
If yes, list:
18. Does the supplier rent Durable Medical Equipment? (42 CFR 424.57(c)(5)) ..........................................................
Yes
No
a. If yes, does the supplier directly service, maintain or replace DME items it rents to beneficiaries?
(42 CFR 424.57(c)(4), 42 CFR 424.57(c)(14)) .....................................................................................................................
Yes
No
Yes
No
b. Do they have a service contract with another supplier? (42 CFR 424.57(c)(14)).....................................................
Attach copy
If yes, identify the company:
Company name
Phone
Street address
City
State
ZIP code
If no to any of the above, provide an explanation:
19. Does the supplier accept returns of substandard (less than full quality for the particular item) or unsuitable items
(inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries?
(42 CFR 424.57(c)(15)) .......................................................................................................................................................
Yes
If no, explain the reasons why:
20. Does the supplier maintain proof of delivery of items furnished to beneficiaries? (42 CFR 424.57(c)(12)) .......
Attach copy
Form CMS-R-263 (XX/XX)
Yes
No
No
5
Records and phone
21. Where are the patient records maintained? (42 CFR 424.57(c)(7)) (check all that apply)
This location
Off-site storage facility
Electronically
No patient records
Supplier refusal/not permitted to view
22. What do these records include? (42 CFR 424.57(c)(7)) (check all that apply)
Physician ordering/referral documentation (42 CFR 424.57(c)(28))
Benefciary communications, such as questions received from benefciaries and progress notes (42 CFR 424.57(c)(7))
Documentation of delivery (42 CFR 424.57(c)(7)), (42 CFR 424.57(c)(12))
Maintenance, repairs, or exchanges (42 CFR 424.57(c)(14))
Proof the supplier provided equipment warranty (42 CFR 424.57(c)(6))
Attach copy
Proof the supplier advises benefciaries that they may either rent or purchase inexpensive or routinely purchased
equipment, and of the capped rental policy (42 CFR 424.57(c)(5))
Attach copy
Proof the supplier provides benefciaries with written information and instructions on how to use Medicare covered items
safely and effectively (42 CFR 424.57(c)(12))
Attach copy
If no, or supplier refused any of the above, provide an explanation:
23. Does the supplier have a written/electronic complaint policy/procedure established?
(42 CFR 424.57(c)(19)) .......................................................................................................................................................
If yes, attach a copy of their complaint policy/procedure.
24. Does the supplier have a written/electronic document for logging complaints? ................................................
If yes, attach a copy of their complaint log. (42 CFR 424.57(c)(13) and 42 CFR 424.57(c)(20))
25. Does the supplier have a business phone number (other than a cellular phone) listed in a
local phone directory under the business name? (42 CFR 424.57(c)(9)).......................................................................
If yes, list the phone number:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
a. How was the phone number verifed (check all that apply)?
White/Yellow Pages
Directory assistance
Search engine
b. Was there phone activity during the site inspection? ...............................................................................................
Contact with beneficiary
26. Is a copy of the current Supplier Standards provided to all Medicare patients? (42 CFR 424.57(c)(16)) ............
27. Does the supplier directly solicit (or utilize any third-party vendors to solicit) beneficiary referrals
via phone? (42 CFR 424.57(c)(11))....................................................................................................................................
If yes to third-party vendor, list company name(s).
If no, describe what methods the supplier uses to obtain new customers.
28. Does the supplier furnish contact information to beneficiaries at the time of delivery?
(42 CFR 424.57(c)(12)) .......................................................................................................................................................
Example: an equipment sticker label listing the supplier’s name and phone number
Attach copy
Form CMS-R-263 (XX/XX)
6
Signature and declaration
I prepared this document, which is the report of my inspection of the noted facility pursuant to their enrollment in the
Medicare program. This report is a true and accurate account of the events that occurred and transpired on the dates described
therein. In taking pictures, I am attesting that no PII was captured in the photographs. I am capable and willing to testify as
a witness at a hearing about the content of this report. The foregoing information is based on my personal knowledge or is
information provided to me in my offcial capacity. I declare under penalty of perjury that this information is true and correct
to the best of my knowledge and belief.
Executed this day
of
, 20
Signature of declarant
Printed name of site visit inspector
Date of inspection (mm/dd/yyyy)
Additional comments
Form CMS-R-263 (XX/XX)
7
| File Type | application/pdf |
| File Title | Site investigation for suppliers of Durable Medical Equipment, |
| File Modified | 2024-07-30 |
| File Created | 2024-07-25 |