Form CMS-10169 Form A

Form Approved
OMB No. 0938-xxxx

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
For CMS Use Only
Supplier Bidder No.

Date Application Received

FORM A: APPLICATION
Item #1: Application for Suppliers
Please read the instructions completely.
Competitive Bid Area (CBA)

Indicate Supplier Type (pick no more than one)
o Individual Supplier with a Single Location
o Supplier with Common Ownership and Multiple Locations

o Primary Network Supplier

Are you a specialty supplier? o Yes o No
Product Category
Select each product category for which the supplier or network is submitting a bid. (Product categories to
be supplied later, for example.)
o Product Group 1
o Product Group 2
o Product Group 3
A. Supplier’s Identifying Information
Provide the legal business name and mailing address as reported to the IRS. Mailing address is the address where
the IRS Form 1099 is to be mailed for this supplier.
Supplier’s Legal Business Name

Mailing Address (Street)

City

State

Telephone Number (Include Area Code)

E-Mail Address

ZIP Code

Fax Number (Include Area Code)

B. Supplier’s Business Information
Indicate the length of time the supplier completing this form has been supplying DMEPOS items in the CBA.
Length of Time Supplying DMEPOS Items in the CBA
Years

Months

C. Supplier’s Primary Physical Address
If the supplier’s primary physical address is not the same as the mailing address, indicate the supplier’s
complete physical address.
Physical Address(es)

City

State

ZIP Code

D. Tax Identification Number
Provide the Tax Identification Number (TIN) issued by the IRS to the supplier completing this form. If a
sole proprietor, social security number may be used.
Tax Identification No. (TIN)

Form CMS-10169A (xx/xx)

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Supplier’s Legal Business Name

Supplier Bidder No.

E. NSC and NPI Identification Number
Provide the NSC and NPI number specific to this business location.
NSC Identification Number

NPI Identification Number

F. Service Type
How will you service beneficiaries in a CBA? Check all that apply:
o Retail Location
o Mail Orders
o Home Delivery
G. DBA – “Doing Business As” Name
Provide the “doing business as” (DBA) if different from the legal business name reported in item A.
Doing Business As (DBA) (If applicable)

Doing Business As (DBA) (If applicable)

H. Additional Physical Location Information
Provide all additional names and related information for the additional physical location(s) in which the
supplier does business.
1. Name of Business

Telephone Number

NSC Number

NPI Number

TIN Number

Physical Address

City

2. Name of Business

State

Telephone Number

NSC Number

ZIP Code

NPI Number

TIN Number

Physical Address

ZIP Code

State

City

I. Accreditation Information for Locations Serving this Competitive Bid Area
Indicate the name(s) of the Medicare-approved organization(s) you are accredited by, or anticipate accreditation
from, and provide the accreditation’s issue and expiration dates. Indicate product specific area(s) you are
accredited (i.e. oxygen, general DME).
1. Legal Business Name

Accrediting Organization

Zip

Status

2. Legal Business Name

Accrediting Organization

Form CMS-10169A (xx/xx)

o Yes
o No o Pending
Zip

Status

o Yes
o No o Pending

Product Specific Area(s)

Issue Date (month/year)

Expiration Date (month/year)

(Current or Expected)

(Current or Expected)

Product Specific Area(s)

Issue Date (month/year)

Expiration Date (month/year)

(Current or Expected)

(Current or Expected)

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Supplier’s Legal Business Name

Supplier Bidder No.

J. Type of Business
Select type of business. If “Other,” briefly describe the supplier’s type of business. Definitions are provided
in the Glossary.
o Business Corporation
o Sole Proprietorship
o General Partnership
o Joint Venture
o Professional Corporation o Franchise
o Publicly Traded Company
o Other______________________________________________________
K. Establishment Information
Enter the two-letter abbreviation for the state in which the supplier completing this form is established or
incorporated. Also provide the date established or incorporated. If incorporated at a previous time, in another
state, please provide the state and date.
Established/Incorporated
State

Previously Established/Incorporated
Date (mm/dd/yyyy)

State

Date (mm/dd/yyyy)

L. Contact Person
Provide the name(s) of the contact person who should be contacted to answer questions regarding the
supplier’s bid.
Contact Person(s) First Name
PRINT

Last Name

Telephone (include area code)

Contact Person(s) First Name
PRINT

Title

E-Mail Address

Last Name

Telephone (include area code)

Title

E-Mail Address

M. Financial Information
1. Credit rating and score (See instructions)
2. Required Financials (See instructions)

Form CMS-10169A (xx/xx)

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Supplier’s Legal Business Name

N. Sanctions
Have you been subject to past or current sanctions?
(If yes, please see instructions.)

Supplier Bidder No.

o Yes o No

O. Key Personnel
Please include a list of names and current title of key personnel of the corporate officers of your company.
Name

Title

Name

Title

Name

Title

Name

Title

Name

Title

P. Additional Information (Optional)
The space provided may be used if additional room is needed to fully respond to other questions on
this form.

Form CMS-10169A (xx/xx)

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Supplier’s Legal Business Name

Supplier Bidder No.

Item #2: Application for Networks
(A) Enter the primary supplier’s NSC and NPI numbers. The NSC and NPI numbers must be specific to the
supplier’s location – not the corporate number.
NSC Number

NPI Number

(B) Enter the primary supplier’s legal business name.
Primary Supplier’s Legal Business Name

(C) List the network’s member suppliers with their NSC and NPI numbers.
Member Legal Business Name

NSC Number

NPI Number

Member Legal Business Name

NSC Number

NPI Number

(D) Are network’s signed, legal contracts between members attached?
If no, the network is ineligible to submit a bid.

o Yes

o No

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-xxxx. The time required to complete this information collection is estimated to average 10 hours per response, including the
time to review instructions, search existing data resources, gather the the data needed, and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.
Form CMS-10169A (xx/xx)

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