CMS-10169 Form C

Form Approved
OMB No. 0938-xxxx

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

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
CONTRACT SUPPLIER QUARTERLY REPORT
FORM C
1. Contract Supplier's Legal Business Name

Supplier Bidder No.

2. If Network, Primary Supplier’s Legal Business Name

3. Competitive Bid Area (CBA)

4. Year

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

5) The following is a listing of items that have been furnished to Medicare Beneficiaries during this quarter.
Approximate
No. Supplied

HCPCS Code

Manufacturer

Model Name

Model No.

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Signature of Authorized Official

Date

Print Name and Title of Authorized Official

Date

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 2 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-10169C (xx/xx)