CMS-1557
SURVEY REPORT FORM - CLIA
Form CMS-1557 is the Survey Report Form (CLIA) from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The form opens with surveyor instructions, and it says each surveyor signs the certifying statement on page 2 for each type of survey conducted. It is a survey record, not a form for patients.
Page 1 records the laboratory's CLIA identification number, name, addresses and director, the survey status and the number of people qualified under each listed regulatory section. Page 2 covers the specialties and subspecialties, two yes or no questions, the regulations reviewed in a partial survey and the compliance statement with signature lines. Pages 3 and 4 are a Survey Worksheet (CLIA).
The form shows OMB No. 0938-0544. You can fill it out free in your browser on this page and download the result without an account.
CLIA identification number, date of survey, laboratory name, telephone number, laboratory and mailing addresses, director's name, state/county code, state region code, state license number (if applicable) and Medicare provider number(s).
Check boxes for each survey type, with lines to name the State for State Exemption, the organization for Accreditation, the (sub)specialty added, or the Other survey type.
The number of people qualified under each applicable regulatory section, for directors, clinical consultants, technical consultants and supervisors at moderate and high complexity, plus cytotechnologists and cytology supervisors.
A table from Histocompatibility (010) to Clinical Cytogenetics (900) with columns for accredited program, annual test volumes, added and deleted effective dates, and proficiency testing.
Yes or no: are immunohematology tests performed for transfusion purposes, and are blood or blood products (including autologous) collected. Then the regulations reviewed in a partial survey and a compliance statement with signature lines.
Pages 3 and 4 carry the page number, name of surveyor, date of survey (MMDDYY), name of facility and CLIA identification number, with open space below.
The form has four pages: the report on pages 1 and 2 and a worksheet on pages 3 and 4.
Fill in the laboratory's CLIA number, name, phone, addresses, director, codes, state license number if applicable and Medicare provider number(s).
Check every survey type that applies and complete the lines for State, organization, (sub)specialty or Other.
Show the number of people qualified under each applicable regulatory section in the personnel grid.
The instructions say to list information and effective dates for any specialty or subspecialty added or deleted, and that comments pertinent to the survey or to compliance can go in the proficiency testing column.
Answer the two yes or no questions. For a partial survey, list the laboratory condition regulation numbers reviewed.
Each surveyor signs and dates page 2 for each type of survey conducted, according to the form's instructions.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form does not print a mailing address for the completed report. The CMS address on page 1 is for comments on the time estimate only, and the form says not to send applications, claims, payments, medical records or sensitive documents there.
The form says questions or concerns about where to submit documents can go to [email protected].
The form shows OMB No. 0938-0544 with an expiration date of 06/30/2025. The CMS page lists the same OMB number and expiration date.
The form estimates an average of 30 minutes per response, including reviewing instructions and gathering the data needed.
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The instructions on the form are written for surveyors. The laboratory is the subject of the report.
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The form's instructions are written for surveyors. It says each surveyor signs the certifying statement on page 2 for each type of survey conducted.
The survey status boxes are Initial Certification, Recertification, Validation, Complaint, State Exemption, Accreditation, Addition of (Sub)Specialty(ies) and Other. The form says to check all that apply.
The form's instructions say any comments pertinent to the survey or determination of compliance can be listed there. Some specialties, such as Histopathology, show NA in that column.
They are a Survey Worksheet (CLIA) with the surveyor's name, the date of survey (MMDDYY), the facility name, the CLIA identification number and a page count.
The form prints an OMB expiration date of 06/30/2025, and the CMS page lists the same date.
The form lists [email protected] for questions or concerns about where to submit documents.
