(General Information, Eligibility, and Entitlement Manual)

IT IS FURTHER C ERTIFIED THAT THE PHOTOGRAPHIC PROCESSES USED FOR MICROFILMING OF THE ABOVE RECORDS WERE ACCOMPLISHED IN A MANNER AND ON MICROFILM THAT MEETS THE RECOMMENDED REQUIREMENTS OF THE NATIONAL BUREAU OF STANDARDS FOR PERMANENT MICROPHOTOGRAPHIC REPRODUCTIONS.   Date Microfilmed      Camera Operator   Location      Authorized Signature   Exhibit 10 - Resolution Test Chart  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  The resolution test chart can also be viewed at the following link:   http://www.efg2.com/Lab/ImageProcessing/TestTargets/#Microcopy      Exhibit 11 - Witness Disposal Certification (Sample)  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06 -26-06)  WITNESSED DISPOSAL CERTIFICATION  Disposal Date:   _____________________ Medicare Contractor:  ________________________________________ Address:    ________________________________________     ________________________________________ Disposal Location:  ________________________________________ _____________________________________________________________  Volume by Cubic Feet (e.g., number of boxes):  ____________________ Description & Year(s) of Records Destroyed: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ I certify that I witnessed th e proper destruction of CMS Medicare records approved for disposal on the date and location named in this document. Print Name:  __________________________________ Title:    __________________________________ Signature:   __________________________________ Date:   ________________ Exhibit 12 - Roll Report  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  ROLL REPORT     CAMERA NO.       LIGHT LEVEL       IRIS      REDUCTION        PROCESSING DEPARTMENT  DATE PROC.       DEV. TIME       CHEM. TEMP       REMARKS       PROCESSOR       INSPECTION DEPARTMENT  APPROVED  RESHOOTS       FOOTAGE       INSPEC.  TIME      INSPECTORS  INTIALS      DENSITY        RESHOOTS WILL BE FOUND ON       THIS ROLL FOR ROLL NUMBERS    THEIR ROLL       NO.  AGENCY       NAME  OUR ORDER       NUMBER   FILMING TIME       LUNCH       TIME  BREAK       TIME  PREP      TIME WAITING       TIME SET-UP      TIME TRAVEL      TIME REMARKS        OPERATORS INITIALS       Exhibit 13  Report of Medicare Records  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  ANNUAL REPORT OF MEDICARE RECORDS   Name & Address of Medicare Contractor      Name, Title and Phone # of the Person Submitting the Report     Type of Medicare Contractor (Carrier/Intermediary/DMERC, etc.)       Current File Room   Offsite Storage   Storage Costs  1. Total Records on Hand at the End of the Reporting Period       a. Magnetic Tape Included in Line 1       b. Microfilm Included in Line 1       c. CDs included in Line 1      d. Paper included in Line 1        2. Records Transferred to Storage During Reporting Period (provide the number of boxes)       a. To Offsite Storage Included in Line 2   $   b. To Onsite Storage Included in Line 2   $ TOTAL STORAGE COSTS (Add 2a+b)    $     3. Total Records in Offsite Storage During the Contract Period      For the purpose of this report, volume may be calculated according to the following table of cubic foot equivalents:   1 record storage box1 cubic foot  Letter -size filing cabinet.1 cubic feet per drawer  Legal -size filing cabinet..2 cubic feet per drawer  Magnetic Tape.1 cubic foot  per 7 reels  Microfilm.1 cubic foot per 108 rolls  CDs.. cubic foot per 12 case holder   Exhibit 14 - Inspection Checklist - Facility Standards for Records Storage Facilities (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implement ation: 06- 26-06)  Facility Standards for Records Storage Facilities  Inspection Checklist (Effective date of checklist September 2005)  Agency:   Facility:  Common Name:   Facility:  Street Address   Facility:  City, State & Zip   Facility Director or Representative:  <<Typed name>>  <<Typed Title>>   Comments explaining or disagreeing with inspection findings are attached.  Inspector:  <<Typed name>>                                                      Date  <<Typed Title>>  Facility Description:           Compliance with 36 CFR 1228.228 Facility Requirements  1228.228 paragraph:  Requirement  OK No Other  (a) The facility must be constructed with non- combustible materials and building elements, including walls, columns, and floors.     (a) exception 1  If the roof is constructed of combustible material it is protected by a properly installed and maintained wet -pipe automatic sprinkler system.     (a) exception 2  Existing records storage facility with combustible building elements has an approved waiver from NAS that allows continued use until October 1, 2009 provided documentation has been submitted that indicates a fire -suppression system designed to mitigate the risk is present.     (b) A facility with two or more stories must be design ed or certified by a licensed fire protection engineer and civil/structural engineer to avoid catastrophic failure of the structure due to an uncontrolled fire on one of the intermediate levels.     (c) The building must be sited a minimum of five feet above and 100 feet from any 100 year flood plain areas, or be protected by an appropriate flood wall (see FEMA flood maps)     (d) The facility must be designed in accordance with national, regional, state or local building codes (whichever is most stringe nt) to provide protection from building collapse or failure of essential equipment from earthquake hazards, tornadoes, hurricanes, and other natural disasters.     (e) Roads, fire lanes, and parking areas must permit unrestricted access for emergency vehicles.     (f) A floor load limit must be established for the records storage area by a licensed structural engineer.  The allowable load limit must be posted in a conspicuous place and must not be exceeded.    (g) The facility must ensure that the roof membrane does not permit water to penetrate the roof. (New buildings: effective 9/28/2005; existing buildings: effective 10/1/2009)     1228.228 paragraph:  Requirement  OK No Other  (h) Piping (with the exception of sprinkler piping and storm water roof drainage piping) must not be run through the records storage area unless supplemental measures  are used to prevent water leaks . (New buildings: effective 9/28/2005; existing buildings: effective 10/1/2009)     (i)(1)  All storage shelving must be designed and installed to provide seismic bracing  that meets the requirements of the applicable state, regional, and local building code (whichever is most stringent).    (i)(2)  Racking systems, steel shelving, or other open- shelf records storage equipment must be braced to prevent collapse under full load.  Each shelving unit must be industrial style shelving rated at least 50 lbs per cubic foot supported by the shelf.     (i)(3)  Compact shelving, if used, must be designed to permit proper air circulation and fire protection     (j) The records storage area must be equipped with an anti -intrusion alarm system  meeting the requirements of UL 1076, Proprietary Burglar Alarm Units and Systems (level AA) . The alarm system must be monitored in accordance with UL 611, Central Station Burglar Alarm S ystems.     (k) The facility must comply with the requirements for a Level III facility. (Appendix A -- see separate checklist)     (l) Records contaminated by hazardous materials  must be stored in separate areas having separate air handling systems from  other records.    (m) The facility must have an Integrated Pest Management program.     (n)  The following additional requirements apply only to new facilities:    (n)(1)    (1) No mechanical equipment containing motors in excess of 1 HP within records storage areas (excluding material handling and conveyance equipment that have operating thermal breakers on the motor).    1228.228 paragraph:  Requirement  OK No Other  (n)(2)   (2) No high- voltage electrical distribution equipment (i.e., 13.2kv or higher) in records storage areas.     (n)(3)    (3) A redundant source of primary electrical service  should be provided  .  Manual switching between sources of service is acceptable.  (See text in rule; applies to HVAC, fire and security alarms.)     (n)(4)  (4) For new facilities that store permanent records:     (n)(4)a   a. A facility storing permanent records must be kept under positive pressure.     (n)(4)b   b. No intake louvers in loading dock areas, parking or other areas subject to vehicle traffic.     (n)(4)c  c. Separate air supply and exhaust system for loading docks.