Site Visit Acknowledgement: By signing this form, you acknowledge that (1) a site inspection was conducted at the physical address by NSC personnel or subcontractors; (2) an employee, owner, or authorized legal representative was present; (3) a copy of the disclosure statement and/or abridged Medicare Supplier Standards was provided. All items checked below must be faxed within 2 business days. Failure to provide requested information may result in denial or revocation of your Medicare supplier billing number.
1
Required Licenses, Including Zoning
All state and local licenses required to operate as a DME supplier are current and on file
Includes business license, state DME license, zoning compliance, and any specialty permits. All must be unexpired.
42 CFR § 424.57(c)(1), (7)
Zoning permits confirm the location is authorized for DME/medical supply operations
If operating from a mixed-use or residential area, zoning variance documentation must be available.
42 CFR § 424.57(c)(1), (7)
2
Credit Agreement(s) or Invoices
Credit agreements and/or invoices from DME product manufacturers or distributors are on file
Must demonstrate legitimate sourcing of DMEPOS items. Invoices should show supplier name, product details, dates, and quantities.
42 CFR § 424.57(c)(4)
3
Capped Rental / Inexpensive or Routinely Purchased Option Agreement
Rental and/or purchase option agreements are available for review
Includes agreements for capped rental items (e.g., hospital beds, wheelchairs) and inexpensive/routinely purchased items. Must show patient signature and terms.
42 CFR § 424.57(c)(5)
4
Proof of Warranty Coverage
Warranty documentation for DMEPOS items supplied to beneficiaries is maintained on file
Must cover manufacturer warranties and any supplier-provided warranties. Documentation should be retrievable by product type.
42 CFR § 424.57(c)(6)
5
Accessibility to Physical Site & Hours of Operation
Physical location is accessible to the public during posted business hours
Location must be open and staffed a minimum of 30 hours per week (unless exempt). If closed for lunch, it must be posted.
42 CFR § 424.57(c)(1), (7)
Business signage with company name is clearly visible from exterior
Sign must be professional, permanent (not handwritten), and visible from the street, parking lot, or building hallway as applicable.
42 CFR § 424.57(c)(7)
Hours of operation are conspicuously posted and visible from outside the facility
Must include days of the week and specific open/close times. Must be visible even when the location is closed.
42 CFR § 424.57(c)(7)
6
Comprehensive Liability Insurance
Current comprehensive liability insurance policy is on file
Policy must cover all DMEPOS items supplied. Must be current (not expired) and provide adequate coverage amounts.
42 CFR § 424.57(c)(10)
Certificate of Insurance names NSC as certificate holder
Certificate must list the NSC address: PO Box 100142, Columbia, SC 29202 as the certificate holder.
42 CFR § 424.57(c)(10)
7
Written Instructions / Information on Beneficiary Use & Maintenance
Written instructions and/or information for beneficiary use and maintenance of supplied items are available
Must provide clear, understandable instructions for each type of equipment or supply delivered. Should include setup, use, cleaning, and troubleshooting.
42 CFR § 424.57(c)(12)
8
Beneficiary Copy of Supplier Standards
A copy of the Medicare Supplier Standards (42 CFR § 424.57) is available to provide to beneficiaries upon request
Must have printed copies readily available. Standards should be the current version and easily accessible to staff for distribution.
42 CFR § 424.57(c)(16)
9
Listing of All Management / Owners
A complete listing of all management personnel and owners is maintained, including full names and titles
Must include all individuals with 5% or greater ownership interest, managing employees, authorized/delegated officials, and board members (if applicable). Must match CMS-855S enrollment.
42 CFR § 424.57(c)(17)
10
Complaint Resolution Protocol & Complaint Log
A written complaint resolution protocol/policy is in place and available for review
Must describe the process for receiving, documenting, investigating, and resolving complaints. Should include timeframes and responsible parties.
42 CFR § 424.57(c)(19)
A complaint log is actively maintained and available for inspection
Log must record: date received, complainant info, nature of complaint, investigation details, resolution, date resolved. Even if zero complaints, the log must exist.
42 CFR § 424.57(c)(20)
11
Surety Bond Agreement
A surety bond in the amount of $50,000 is current and on file
Bond must be from an authorized surety company listed in the U.S. Treasury Circular 570. Must name CMS as the obligee. Must not be expired.
42 CFR § 424.57(c)(26)
12
License of Oxygen Supplier / Distributor / Wholesaler
If applicable — oxygen supplier, distributor, or wholesaler license is current and on file
Required only if supplying oxygen or oxygen equipment. Must comply with state and federal requirements for oxygen handling, storage, and distribution.
42 CFR § 424.57(c)(27)
13
Other Items Requested by Inspector
Additional item: _______________________________________________
As specified by the inspector during the visit. Must be faxed within 2 business days if checked.
Additional item: _______________________________________________
As specified by the inspector during the visit. Must be faxed within 2 business days if checked.
Additional item: _______________________________________________
As specified by the inspector during the visit. Must be faxed within 2 business days if checked.
CRITICAL REMINDER: All items checked above by the inspector must be faxed to 1-800-568-9733 (Attn: Gail Hudgens) within 2 business days. Failure to provide requested information may result in denial or revocation of your Medicare supplier billing number.
NSC Contact Information
- Fax for Requested Items
- 1-800-568-9733
- Attention
- Gail Hudgens
- NSC Customer Service
- (866) 238-9652
- Compliance Forms
- palmettogba.com/nsccomplianceforms