Form CMS-10169 Form A - APPLICATION FOR DMEPOS COMPETITIVE BIDDING PROG

Form Approved

OMB No. 0938-1016

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

FORM A: APPLICATION FOR DMEPOS COMPETITIVE BIDDING PROGRAM
NOTE: Please read all instructions completely. Suppliers with a single location or multiple locations must complete
Section 1 -1a: Application for Suppliers. Networks, however, must complete Section 2-2b: Application for Networks.

Indicate how your Business Organization will be Bidding (choose only one):

o
o
o

Supplier with a Single Location (Complete Section 1-1a)
Supplier with Multiple Locations (Complete Section 1-1 a)
Network (Complete Section 2-2b)

Section 1: Application for Suppliers
Are you a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) that is bidding as a specialty
supplier that will provide competitively bid items only to its own residents?
0 Yes 0 No
A. Supplier's Identifying Information
Provide the legal business name and mailing address where correspondence will be sent to you by the Competitive Bidding
Implementation Contractor (CBIC). This mailing address must match the mailing address on file with the National Supplier
Clearinghouse (NSC) provided in Section 2.A.2 on the Medicare Enrollment Application Form CMS-855S.
Legal Business Name,

--;:=,....,--==----c---,-;--,;-c;;c-_---,-.,..,.,._---c----c-,-,--_==::-;-

_

(NOT your billing agent, staffing company, or managing organization)

Mailing Address Line 1

",.,.......,...".-_--,-".-=-.,.-

_

(Street Name and Number)

Mailing Address Line 2 - - - - - - - - - - - - - = 7 : " = : = - = ; - - - - - - - - - - - - - - - - - - - ­
(Suite, Room, etc.)

Cityrrown,
Telephone Number

State,
Fax Number

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

Zip,
_ E-mail,

_

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.
TIN
_

Form CMS-IOI69A (04107) EF (04/2007)

_
_

Supplier's Legal Business Name

Supplier's Bidder No.

B. Supplier's Physical Address
DYes 0 No

Is the supplier's mailing address the same as the supplier's physical address provided in Question A.?
If the answer is No, please complete the following information:

-..",===-====

Physical Address Line 1

(Street

Physical Address Line 2

_

Name and Number)

----::::-::----=,---_,....,..

_

(Suite, Room, etc.)

CityfTown

State

Zip

_

C. "Doing Business As" (DBA) Name
Indicate the DBA name if different from the legal business name reported in Question A.

DBA (if applicable)

_

DBA (ifapplicable)

_

D. Establishment Information
Identify the two-letter abbreviation for the state in which your company was established or incorporated.

Establishedllncorporated State

_

Indicate the length of time (number of months and years) this location has been in the business of furnishing DMEPOS items to

any customer (including both Medicare and non-Medicare customers).

Months

Years.

in business

E. 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
Title,
Last Name
(PRINT)
E-Mail Address,
Telephone (include area code)
Contact Person(s) First Name

-----,===­

_

Last Name

Title,

_
_
_

(PRINT)
Telephone (include area code)

_

E-Mail Address,

_

F. Key Personnel
Provide the name(s) and title(s)of the authorized official(s) or key personnel for the business organization.
Last Name
Title,
Contact Person(s) First Name
(PRINT)
Telephone (include area code)
E-Mail Address
Contact Person(s) First Name

---,===-

Last

Name~

Title.

_
_
_

(PRINT)
Telephone (include area code)

Form CMS-10169A (04/07) EF (04/2007)

E-Mail Address

_

Supplier's Bidder No.

Supplier's Legal Business Name

G. Type of Business

Select the business type for the location identified by the NSC number in Question A. If "Other", briefly describe the supplier's

type of business. Bidders must submit certain financial documentation based on the type of business identified in this response.

Refer to Section III.C.1 of the Request for Bid (RFB) instructions for a list of required documents.

o Corporation (LLC, Professional Corporation, S Corp and C Corp) 0
o Sole Proprietorship
o Partnership
0

Municipality and State Owned
Non Profit Organization

H. Service Delivery

For the location identified in Question A., how will you service beneficiaries in a CBA? (Check all that apply)

o Retail Location
.
o Mail Order
o Home Delivery

I. Sanctions

Indicate whether the location identified in Question A or any other location has been subject to any past or current legal actions,

sanctions, including debarmljlnts?

(If yes, please see RFB instructions)
0 Yes 0 No

J. Accreditation Information

Is the location identified in question A. accredited by a Medicare approved accreditation organization?

DYes 0 No

If the answer is yes, what is the name of the Medicare approved accreditation organization?
For which product specific area(s) are you accredited? ,-Indicate your accreditation issue date and expiration date:
Issue Date (MonthlYear)
(Current or Pending)

_

Expiration Date (MonthlYear)
(Current or Pending)
DYes 0 No

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?

K. Indicate the CBA(s) and the Product Category(s) for which this location is submitting a bid.
Charlotte N.C.

Cincinnati

Cleveland

o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o Oxygen Supplies
0 Walkers
o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o

Dallas/Ft. Worth

Kansas City

o
o

Miami
o Oxygen Supplies

0 Walkers

o Oxygen Supplies
0 Walkers
o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o
o

Orlando

Pittsburgh

Riverside

o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o Oxygen Supplies
0 Walkers
o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o Oxygen Supplies
0 Walkers
0 CPAP
o Enteral Nutrition
Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o

Form CMS-10169A 104/(7) EF (04/2007)

o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o

Enteral Nutrition

0 CPAP

o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs 0 Support Surf

o

Supplier's Legal Business Name

Supplier's Bidder No.

Section 1a. Location-Specific Questions
L. Additional Physical Location Information
Provide the requested information for each location in your business organization. You must provide the unique NSC number
that applies to each location.

Legal Business Name
DBA (if different)

Physical Address Line 1

--;;:===,.-:-:===

_

(Street Name and Numbar)

Physical Address Line 2

----,,,....,,----;,,---.,,--

_

(Suite, Room, h',.

Z,p,

CityfTown
~;".e.-:-;
Toll Free N"'u-m--'-b-e-r- - - - - - - - - - - - - - - - - - - - - - ; E = - - m a " address:
NSC Number (for this location)
NPI Number (for this location)

_

--::=-,-,-_,---

_

TIN Number

_

List the CBA(s) and product categories for which this location is bidding.

Charlotte N.C.

Cleveland

Cincinnati

o Oxygen Supplies

0 Walkers

o Oxygen Supplies

0 Walkers

o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

Dallas/Ft. Worth

Kansas City
o Oxygen Supplies
o Enteral Nutrition

o Oxygen Supplies
o Enteral Nutrition

0 Walkers
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

Orlando
o Oxygen Supplies
0 Walkers
o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

o
o

0 Walkers
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

Pittsburgh
o Oxygen Supplies
o Enteral Nutrition
o Mail-Order Diabetic Supplies
o Standard Power Wheelchairs

0 Walkers
0 CPAP
0 Hospital Beds

o
o

o

Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o
Miami
o Oxygen Supplies
o Enteral Nutrition
o Mail-Order Diabetic Supplies
o Standard Power Wheelchairs
Riverside
o Oxygen Supplies

o

o

o

0
0
0
0

Walkers
CPAP
Hospital Beds
Support Surf

0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

Accreditation
Is the location identified in Question L. accredited by a Medicare approved accreditation organization?
DYes 0 No
If the answer is yes, what is the name of the Medicare approved accreditation organization?
For which product specific area(s) are you accredited?
Indicate your accreditation issue date and expiration date:
Issue Date (MonthlYear)
(Current or Pending)

_

Expiration Date (MonthlYear)
(Current or Pending)

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?

o Yes 0

No
_

Supplier Business Information
Indicate the length of time (number of months and years) this location has been in the business of furnishing DMEPOS items to
Medicare and non-Medicare customers.
Months,

Years

in business

M. Additional Information (Optional)
The space provided may be used if additional space is needed to fully respond to other questions on this form.
Fonn CMS-10169A (04/07) Ef (04/2007)

FORM A: APPLICATION FOR NETWORKS
NOTE: Please read all instructions completely. The primary network supplier must complete this
application in order to bid on behalf of a network.
Indicate how your Business Organization will be Bidding (choose only one):

o
o
o

Supplier with a Single Location (See Application for Suppliers)
Supplier with Multiple Locations (See Application for Suppliers)
Network

Section 2: Application for Networks
A. Primary Network Member Supplier's Identifying Information
Provide the legal business name and mailing address where correspondence will be sent to you by the Competitive Bidding
Implementation Contractor (CBIC). This mailing address must match the mailing address provided in Section 2.A.2 on the
Medicare Enrollment Application Form CMS-855S.
Legal Business Name

--;;;======-::;:====-=======:;-

_

===,..,.-,===::;-

_

=-,,--;:-_--,--,--

_

(NOT your billing agent, staffing company,

Mailing Address Line 1

or managing organization)

(Street Name and Number)

Mailing Address Line 2

(Suite, Room, etc.)

CitylTown
Telephone Number

State,
_

Fax Number

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

Zip
_ E-mail Address

_

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.
TIN
_

rorm CMS-10169A (04107) EF (0412007)

_
_

Supplier's Legal Business Name

Supplier's Bidder No

B. Primary Network Supplier's Physical Address
Is the supplier's mailirlg address the same as the supplier's physical address provided in Section 2, Question A.? 0 Yes 0 No
If the answer is No, please complete the following information:

Physical Address Line 1

========

_

(Street Name and Number)

Physical Address Line 2

-..",=-;;=,.....",.,..,(Suite, Room, etc.)

CityfTown

State,

_

Zip,

_

C. "Doing Business As" (DBA) Name
Provide the DBA name if different from the legal business name reported in Question A.
DBA (if applicable),

_

DBA (if applicable)

_

D. Establishment Information
Identify the two-letter abbreviation for the state in which your company was established or incorporated,
Established!1 ncorporated State

_

Indicate the length of time (number of months and years) this location has been in the business of furnishing DMEPOS items to
any customer (including both Medicare and non-Medicare customers),
in business
Months
Years

E. 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
Last Name
Title,
(PRINT)
Telephone (include area code)
_ E-Mail Address,
Last Name,

Contact Person(s) First Name

Title

_
_
_

(PRINT)
_ E-Mail Address,

Telephone (include area code)

_

F. Key Personnel
Provide the name(s) and title(s)of the authorized official(s) or key personnel for the business organization,
Titie,
Contact Person(s) First Name
Last Name
(PRINT)
_ _ _ _ _ _ _ _ E-MaiIAddress
Telephone (include area code)

---,==;:;-

Last Name
(PRINT)
Telephone (include area code) _ _ _ _ _ _ _ _ _ _ E-Mail Address
Contact Person(s) First Name

Form CMS-10169A (04/07) EF (0412007)

Title,

_
_
_
_

Supplier's Legal Business Name

Supplier's Bidder No.

G. Type of Business
Select the business type for the location identified by the NSC number in Section 2, Question A If "Other", briefly describe the
supplier's type of business. Bidders must submit certain financial documentation based on the type of business identified in this
response. Refer to Section III.C.1 of the Request for Bid (RFB) instructions for a list of required documents.

o Corporation (LLC, Professional Corporation, S Corp and C Corp) 0
o Sole Proprietorship
DPartnership
0

Municipality and State Owned
Non Profit Organization

H. Service Delivery
For the location identified in Section 2, Question A, how will you service beneficiaries in a CBA? (Check all that apply)
o Retail Location
o Mail Order
o Home Delivery

I. Sanctions
Indicate whether the location identified in Question A or any other location has been subject to any past or current legal actions,
0 Yes 0 No
sanctions, including debarments? (If yes, please see RFB instructions)

J. Accreditation Information
Is the location identified in Section 2, Question A accredited by a Medicare approved accreditation organization? 0 Yes 0 No
If the answer is yes, what is the name of the Medicare approved accreditation organization?
For which product specific area(s) are you accredited?
Indicate your accreditation issue date and expiration date:

Issue Date (MonthlYear)
(Current or Pending)

_

Expiration Date (MonthlYear)
(Current or Pending)

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?

DYes 0 No
_

K. Indicate the CBA(s) and the Product Category(s) for which this location is submitting a bid.
Charlotte N.C.

Cincinnati

o Oxygen Supplies
o Enteral Nutrition

o Oxygen Supplies

0 Walkers
0 CPA?
o Mail-Order Diabetic Supplies 0 Hospital Beds

o Standard Power Wheelchairs
Dallas/Ft. Worth

o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPA?
o Mail-Order Diabetic Supplies 0 Hosprtal Beds

o

Standard Power Wheelchairs

o

Orlando
o Oxygen Supplies
Enteral Nutrition

o

0 Walkers
0 CPA?

o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

Form CMS-IO 169A (04/07) EF (04/2007)

0 Walkers

o Enteral Nutrition
0
o Mail-Order Diabetic Supplies 0
o Standard Power Wheelchairs
Kansas City
o
o

0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

CPA?
Hospital Beds

o

Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o
o

Oxygen Supplies
Enteral Nutrition
Mail-Order Diabetic Supplies
Standard Power Wheelchairs

0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o

Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o
o
Pittsburgh
o Oxygen Supplies
o
o
o

Cleveland
o Oxygen Supplies

o

o
Miami

o
o
Riverside
o

o

o

0
0
0
0

Walkers
CPAP
Hospital Beds
Support Surf

Supplier's Legal Business Name

Supplier's Bidder No.

Section 2a: Location-Specific Questions for Primary Network Supplier
L. Additional Physical Location Information for Primary Network Supplier
Please provide the requested information for each location in your business organization. You must provide the unique NSC
number that applies to each location. The primary network member should provide information for all of its locations first.
Legal Business Name--;Physical Address Line 1

DBA (if different)

_

---------=---,...,.,---.,...,-,----,----,-----------------­
(Street Name and Number)

--;;:=----===-==

Physical Address Line 2

_

(Suite, Room, etc.)

CilyrTown.-,----,LToll Free Number
NSC Number (for this locatiorl)

----=:----::-----, State
Zip
_
E-mail address:~~~~~~~~~~;;...,..,_-,___------_
NPI Number (for this location),
TIN Number
_

List the CBA(s) and product category(s) for which this location is bidding.

Charlotte N.C.

Cincinnati

o Oxygen Supplies
0 iWalkers
o Enteral Nutrition
0 'CPAP
o Mail-Order Diabetic Supplies 0 ~osPital Beds
o Standard Power Wheelchairs

o Oxygen Supplies
0 Walkers
o Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds
o Standard Power Wheelchairs

Dallas/Ft. Worth

Kansas City
o Oxygen Supplies

o
o
o
o

Oxygen Supplies
0 Walkers
Enteral Nutrition
0 ICPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

Orlando
o Oxygen Supplies
0 Walkers
Enteral Nutrition
0 CPAP
o Mail-Order Diabetic Supplies 0 Hospital Beds

o
o

Standard Power Wheelchairs

o

o

0 Walkers
Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o
Pittsburgh

o Oxygen Supplies

o
o
o

0 Walkers

Enteral Nutrition
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

Cleveland
o Oxygen Supplies
o Enteral Nutrition

o

0 Walkers
0 CPAP
Mail-Order Diabetic Supplies 0 Hospital Beds
Standard Power Wheelchairs

o
Miami
o Oxygen Supplies
o Enteral Nutrition

o

0
0
Mail-Order Diabetic Supplies 0
Standard Power Wheelchairs 0

o
Riverside
o Oxygen Supplies
o Enteral Nutrition
o Mail-Order Diabetic Supplies

o

Walkers
CPAP
Hospital Beds
Support Surf

0 Walkers
0 CPAP
0 Hospital Beds

Standard Power Wheelchairs

M. Accreditation Information for Locations Serving this CBA
Is the location identified in Section 2a, Question L. accredited by a Medicare approved accreditation organization? 0 Yes 0 No
If the answer is yes, what is the name of the Medicare approved accreditation organization?
For which product specific area(s) are you accredited? .
Indicate your accreditation issue date and expiration date:
Issue Date (MonthlYear)
(Current or Pending)

_

Expiration Date (MonthlYear)
(Current or Pending)

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?

DYes 0 No
_

N. Supplier Business Information
Provide the length of time (number of months and years) this location has been in the business of furnishing DMEPOS items to
any customer (including Medicare and non-Medicare customers).
Months
Years
in business

Form CMS-10169A (04107) EF (04/2007)

Supplier's Legal Business Name

Supplier's Bidder No.

Section 2b: Additional Network Member Information
O. Network Member's Identifying Information
Provide the legal business name and physical address.
1. Legal Business Name

==-_..,.""....._--,---,-:-

..,.-_".....,....,.,....,.

_

(NOT your billing agent, staffing company, or managing organization)

"""'=======

Physical Address Line 1

_

(Street Name and Number)

Physice! Mdress Line 1----------------;=;::--c==-=
(Suite, Room, etc..'"
CityfTown,

------------------

State

Telephone Number

Fax Number

Zip
_

_

E-mail Address

NSC and NPlldentification Number
Provide the NSC and NPI number specific to this business location

NSC Identification Number
NPI Identification Number

_

_

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.
TIN
_
Accreditation
Is this location of the network member accredited by a Medicare approved accreditation organization?

o Yes 0

No

If the answer is yes, what is the name of the Medicare approved accreditation organization?

For which product specific area(s) is this location accredited?
Indicate the accreditation issue date and expiration <''lte:
Issue Date (MonthlYear)
(Current or Pending)

_

Expiration Date (MonthlYear)
(Current or Pending)
DYes 0 No
_

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?
Additional Network Member
2. Legal Business Name

_

====================
(NO T your billing agent, staffing company, or managing organization)

_

--",==,.--_===

Physical Address Line 1

_

(Street Name and Number)

Physical Address Line 1

---::;;-;;----;=-::-=

_

(Suite, Room, e!".)

CityfTown,
Telephone Number

Fonn CMS-10169A (04/07) EF (04/2007)

State.
_

Fax Number

Zip
_

E-mail Address

_
_

Supplier's Legal Business Name

Supplier's Bidder No.

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

_

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.
TIN
_
Accredl~ation

Is this Ic'Oation of the network member accredited by a Medicare approved accreditation organization?

DYes 0 No

If the answer is yes, what is the name of the Medicare approved accreditation organization?
For which product specific area(s) is this location accredited?
Indicate the accreditation issue date and expiration date:
issue Date (MonthlYear)
(Current or Pending)

Expiration Date (MonthlYear)
(Current or Pending)

If the answer is no, is accreditation pending for this location?
For which product specific area(s) is accreditation pending?

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

"orm CMS-10169A (04/07) EF (04/2007)

DYes 0 No
_