Form CMS-10169 CMS-10169.RFB Form C

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

Form Approved
OMB No. 0938-1016

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
CONTRACT SUPPLIER INITIAL AND QUARTERLY REPORT
1.Contract Supplier’s Legal Business Name

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

3. Competitive Bid Area (CBA)

4. Year

st

1 Quarter

nd

2 Quarter

rd

3 Quarter

th

4 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

Make

Model No.

__________________ __________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________ __________________

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 0938-1016. The time required to complete this information collection is estimated to
average 14 hours per response, including the time to review instructions, search existing data resources, gather 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.

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Form CMS-10169C (07/09) EF(07/2009)