Information Collection Request

Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

ICR 201207-0938-007 · OMB 0938-1016 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10169 Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (Forms A, B, C) Form and Instruction Removed Available
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure Form and Instruction New Source copy available
Form CMS-10169 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction New Repair queued
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) Form and Instruction New Source copy available
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B) Form and Instruction New Available
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A) Form and Instruction New Available
Form CMS-10169 Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (Form D) Form and Instruction Removed Available
60-Day Comment Response for PRA CMS-10169.docx Supplementary Document Uploaded 2012-07-25 Available
Form B-6.jpg Supplementary Document Uploaded 2012-07-25 Available
Form B-5.jpg Supplementary Document Uploaded 2012-07-25 Available
Form B-4.jpg Supplementary Document Uploaded 2012-07-25 Available
Form B-3.jpg Supplementary Document Uploaded 2012-07-25 Repair queued
Form B-2.jpg Supplementary Document Uploaded 2012-07-25 Available
Form B-1.jpg Supplementary Document Uploaded 2012-07-25 Available
6-cbas and product categories Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
5-additional locations Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
4-add location Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
3-CBAs and Product Categories Screen View.JPG Supplementary Document Uploaded 2012-07-25 Repair queued
2-Location Specific Information Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
1-Business Org Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
1 Network Business Org Screen View.JPG Supplementary Document Uploaded 2012-07-25 Available
CMS-10169.Crosswalks for Form A.xlsx Supplementary Document Uploaded 2012-07-25 Available
CMS-10169 Supporting Statement Part A - 2012.docx Supporting Statement A Uploaded 2012-07-25 Available

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
10/31/2015 36 Months From Approved 10/31/2012
16,865 0 10,100
34,795 0 443,400
0 0 0





Reginfo record details
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table that charts list of burden
IC Title Form No. Form Name
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A) CMS-10169 Application for Suppliers
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B) CMS-10169 Form B - Bidding Form
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) CMS-10169 Form C Quarterly Report
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) CMS-10169 Beneficiary Survey
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure CMS-10169 Subcontracting Disclosure Form
Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (Forms A, B, C) CMS-10169, CMS-10169, CMS-10169 CMS-10169.RFB Form C ,   CMS-10169.RFB Form A ,   CMS-10169.RFB Form B
Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (Form D) CMS-10169 CMS-10169.REVISED RFB Form D
Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (Subcontracting)

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 16,865 10,100 0 6,765 0 0
Annual Time Burden (Hours) 34,795 443,400 0 -408,605 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
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