Form CMS-10169 Application for Suppliers

DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-1016

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM

For CMS Use Only

Supplier Bidder No. Date Application Received

Competitive Bid Area (CBA)

Supplier’s Identifying Information

Supplier’s Legal Business Name Primary Supplier’s Legal Business Name (if network)

FORM A: APPLICATION FOR DMEPOS COMPETITIVE BIDDING PROGRAM

NOTE: Please read all instructions completely. Suppliers with a single location or multiple locations must complete Sections 1 & 1a: Application for Suppliers & Section 1b for each additional location. Networks, however, must complete Sections 2 & 2a: Application for Networks.

Section 1: Application for Suppliers

A. Business Organization Information

Indicate how your business organization will be bidding.

Legal Business Name____________________________________________________________________________________

• Supplier with a Single Location (Complete Section 1-1a)

• Supplier with Multiple Locations (Complete Section 1,1a, & 1b)

• Network (Complete Section 2-2a)

If you selected “Supplier with Multiple Locations”, select one of the following that best describes your business organization structure.

• Subsidiary of a parent company/holding company

• Commonly owned or commonly controlled

• National Chain

• Franchise

• None of the above

B. Specialty Supplier

Are you a Skilled Nursing Facility (SNF) or Nursing Facility (NF) that is bidding as a specialty supplier that plans to provide competitively bid items only to its own residents?  Yes  No

C. Contact Person(s)

Provide the name(s) of the person(s) who should be contacted to answer questions regarding the business or network organization.

Contact Person(s) First Name__________________________ Last Name________________________ Title______________

(PRINT)

Telephone (include area code)_________________________ E-Mail Address_______________________________________

Supplier’s Legal Business Name Supplier’s Bidder No.

D. Authorized Official(s) or Key Personnel

Provide the name(s) and title(s) of authorized official(s) or key personnel for the business or network organization.

Authorized Official(s) or Key Personnel:

First Name__________________________ Last Name________________________ Title______________

(PRINT)

E. Competitive Bidding Area (CBA) and Product Category

Select all of the CBA(s) and product category(s) for which your business organization or network is submitting a bid(s).

Competitive Bidding Areas:

Cincinnati – Middletown (Ohio – Kentucky – Indiana)
Cleveland – Elyria – Mentor (Ohio)
Charlotte – Gastonia – Rock Hill (North Carolina – South Carolina)
Dallas – Fort Worth – Arlington (Texas)
Kansas City (Missouri – Kansas)
Miami – Fort Lauderdale – Pompano Beach (Florida)
Orlando – Kissimmee - Sanford (Florida)
Pittsburgh (Pennsylvania)
Riverside – San Bernardino – Ontario (California)

Product Categories:

Respiratory Equipment and Related Supplies and Accessories
Standard Mobility Equipment and Related Accessories
General Home Equipment and Related Supplies and Accessories
Enteral Nutrients, Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
External Infusion Pumps and Supplies

F. Accreditation

All supplier locations must be accredited for the product category(s) for which the supplier is submitting a bid. As required by 42 CFR §414.414 (c), each supplier location must meet quality standards and be accredited in order to be awarded a contract. This includes all product-specific standards. Select the name(s) of the Medicare-approved organization(s) that has accredited your business organization.

Accrediting Organization __________________________________

Supplier’s Legal Business Name Supplier’s Bidder No.

G. Licensure

The bidder is responsible for having a copy of the applicable state license(s) on file with the National Supplier Clearinghouse (NSC) before they submit a bid. Bids will be disqualified if a bidder does not meet all state licensure requirements for the applicable product categories and for every state in a CBA. Every supplier location is responsible for having all applicable license(s) for each state in which it provides services. For a multi-state CBA the bidder must collectively have all applicable license(s) for every state in the CBA. Each location is not required to have licenses for every state in the CBA as long as each state has a bidding location licensed for the product category.

See the CBIC website for a listing of CBAs.

“I understand that each supplier location is responsible for having all applicable state licenses for each state in which it provides services. Each location is not required to have licenses for every state in the CBA as long as there is a licensed location for each state.” 

* Some states may not require a license to furnish items in a specific product category. Please check the DMEPOS State License Directory on the NSC website and the Licensure for Bidding Suppliers fact sheet on the CBIC website to verify licensure requirements.

Supplier’s Legal Business Name Supplier’s Bidder No.

Section 1a. Location-Specific Questions

Please provide the requested information for each location in your business organization. You must provide the unique National Supplier Clearinghouse (NSC) Provider Transaction Access number (PTAN) that applies to each location. The NSC PTAN is hereafter referred to as PTAN. If you are bidding as a network, the primary network member should provide information for all its locations first.

H. Identifying Information

Provide the legal business name and mailing address for the business organization identified by the PTAN below.

Legal Business Name_____________________________________

Address Line 1___________________________________________________________________________________

(Street Name and Number)

Address Line 2___________________________________________________________________________________

(Suite, Room, etc.)

City/Town_________________________________________________ State__________________ Zip__________________

Telephone Number______________________ Toll Free Number (if available) ___________________________

E-mail address:_________________________________

PTAN for this location_______________ NPI Identification Number ______________

I. Physical Address

Is the supplier’s mailing address the same as the supplier’s physical address provided in Section 1a, Question H.?  Yes  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.)

City/Town_________________________________________________ State__________________ Zip__________________

J. Business Information

Provide the identifying information for the location as identified by the PTAN above in the identifying information question.

TIN Number______________

Doing Business As Name (DBA 1) ____________________________

Doing Business As Name(DBA 2) ____________________________

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

K. Type of Business

Select the business type that describes this location as identified by the PTAN above. Bidders must submit certain financial documentation based on the type of business identified in this response. See the DMEPOS Competitive Bidding Program website at www.dmecompetitivebid.com/financialrequirements for further information.

 Corporation (LLC, Professional Corporation, S Corp and C Corp)  Municipality and State Owned  Other

 Sole Proprietorship  Partnership  Non-Profit Organization

L. Service Delivery

For the location identified above, how will you service beneficiaries? (Check all that apply.)

 Retail Location  Home Delivery  Mail Order

Supplier’s Legal Business Name Supplier’s Bidder No.

M. Sanctions

Indicate whether this location, as identified by the PTAN above, has been subject to any current or past legal actions, or sanctions, such as debarments, with the past 5 years.

Does this location have any current or past legal actions, or sanctions such as debarments?  Yes  No

N. CBA and Product Category

You must associate this location with specific CBA/Product Category(s) where it will furnish items and services in order to be eligible to receive Medicare Payment for competitively bid items. Select the CBA(s)/product category(s) associated with this location.

Competitive Bidding Areas:

Cincinnati – Middletown (Ohio – Kentucky – Indiana)
Cleveland – Elyria – Mentor (Ohio)
Charlotte – Gastonia – Rock Hill (North Carolina – South Carolina)
Dallas – Fort Worth – Arlington (Texas)
Kansas City (Missouri – Kansas)
Miami – Fort Lauderdale – Pompano Beach (Florida)
Orlando – Kissimmee – Sanford (Florida)
Pittsburgh (Pennsylvania)
Riverside – San Bernardino – Ontario (California)

Product Categories:

Respiratory Equipment and Related Supplies and Accessories
Standard Mobility Equipment and Related Accessories
General Home Equipment and Related Supplies and Accessories
Enteral Nutrients, Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
External Infusion Pumps and Supplies

O. Add location

All locations that conduct business within a CBA and provide the product category for which you are bidding must be listed below. It is important that bidders identify all locations by PTAN that will provide competitively bid items in a CBA. Only those locations entered on the bid will be identified on the contract and be eligible to receive payment for the competitively bid item(s). If you are bidding as a network, the primary network member should add its location first. If there are members of the network with multiple locations, the primary network member should add these members’ locations after the primary network member’s location.

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Supplier’s Legal Business Name Supplier’s Bidder No.

Section 1b. Additional Locations

Location-Specific Questions

Please provide the requested information for each location in your business organization. You must provide the unique National Supplier Clearinghouse (NSC) Provider Transaction Access Number (PTAN) that applies to each location. The NSC PTAN is hereafter referred to as PTAN.

G. Identifying Information

Provide the legal business name and mailing address for the location identified by the PTAN below. Important Note: The PTAN identified in this section must correspond with the location being identified in this section.

Legal Business Name_____________________________________

Address Line 1___________________________________________________________________________________

(Street Name and Number)

Address Line 2___________________________________________________________________________________

(Suite, Room, etc.)

City/Town_________________________________________________ State__________________ Zip__________________

Telephone Number______________________ Toll Free Number___________________________

E-mail address:_________________________________

PTAN for this location_______________ NPI Identification Number______________

H. Physical Address

Is the supplier’s mailing address the same as the supplier’s physical address provided in Section 1a, Question G.?  Yes  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.)

City/Town_________________________________________________ State__________________ Zip__________________

I. Business Information

Provide the length of time in business for this location as identified by the PTAN above.

Doing Business As Name (DBA 1) ____________________________

Doing Business As Name (DBA 2) ____________________________

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

J. Sanctions

Indicate whether this location, as identified by the PTAN above, has been subject to any current or past sanctions within the past 5 years?

Does this location have any current or past legal actions, or sanctions such as debarments?  Yes  No

Supplier’s Legal Business Name Supplier’s Bidder No.

K. CBA and Product Category

You must associate this location with specific CBA/Product Category(s) where it will furnish items and services in order to be eligible to receive Medicare Payment for competitively bid items. Select the CBA(s)/product category(s) associated with this location.

Competitive Bidding Areas:

Cincinnati – Middletown (Ohio – Kentucky – Indiana)
Cleveland – Elyria – Mentor (Ohio)
Charlotte – Gastonia – Rock Hill (North Carolina – South Carolina)
Dallas – Fort Worth – Arlington (Texas)
Kansas City (Missouri – Kansas)
Miami – Fort Lauderdale – Pompano Beach (Florida)
Orlando – Kissimmee – Sanford (Florida)
Pittsburgh (Pennsylvania)
Riverside – San Bernardino – Ontario (California)

Product Categories:

Respiratory Equipment and Related Supplies and Accessories
Standard Mobility Equipment and Related Accessories
General Home Equipment and Related Supplies and Accessories
Enteral Nutrients, Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
External Infusion Pumps and Supplies

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM

For CMS Use Only

Supplier Bidder No. Date Application Received

Competitive Bid Area (CBA)

Supplier’s Identifying Information

Supplier’s Legal Business Name Primary Supplier’s Legal Business Name (if network)

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):

• Supplier with a Single Location (See Application for Suppliers)

• Supplier with Multiple Locations (See Application for Suppliers)

• Network

Section 2: Application for Networks

A. Business Organization Information

Has each network member signed a contract to join this network?  Yes  No

Network Name_____________________________________________________

B. Specialty Supplier

Are you a Skilled Nursing Facility (SNF) or Nursing Facility (NF) that is bidding as a specialty supplier that plans to provide competitively bid items only to its own residents?  Yes  No

C. Contact Person(s)

Provide the name(s) of the person(s) who should be contacted to answer questions regarding the business or network organization.

Contact Person(s) First Name__________________________ Last Name________________________ Title______________

(PRINT)

Telephone (include area code)_________________________ E-Mail Address_______________________________________

D. Authorized Official(s) or Key Personnel

Provide the name(s) and title(s) of the authorized official(s) or key personnel for the business or network organization.

Authorized Official(s) or Key Personnel

First Name__________________________ Last Name________________________ Title______________

(PRINT)

E. Competitive Bidding Area (CBA) and Product Category

Select all of the CBA(s) and product category(s) for which your business organization or network is submitting a bid(s):

Supplier’s Legal Business Name Supplier’s Bidder No.

Competitive Bidding Areas:

Cincinnati – Middletown (Ohio – Kentucky – Indiana)
Cleveland – Elyria – Mentor (Ohio)
Charlotte – Gastonia – Rock Hill (North Carolina – South Carolina)
Dallas – Fort Worth – Arlington (Texas)
Kansas City (Missouri – Kansas)
Miami – Fort Lauderdale – Pompano Beach (Florida)
Orlando – Kissimmee – Sanford (Florida)
Pittsburgh (Pennsylvania)
Riverside – San Bernardino – Ontario (California)

Product Categories:

Respiratory Equipment and Related Supplies and Accessories
Standard Mobility Equipment and Related Accessories
General Home Equipment and Related Supplies and Accessories
Enteral Nutrients, Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
External Infusion Pumps and Supplies

F. Accreditation

All supplier locations must be accredited for the product category(s) for which the supplier is submitting a bid. As required by 42 CFR §414.414 (c), each supplier location must meet quality standards and be accredited in order to be awarded a contract. This includes all product-specific standards. Select the name(s) of the Medicare-approved organization(s) that has accredited your business organization.

Accrediting Organization __________________________________

G. Licensure

The bidder is responsible for having a copy of the applicable state license(s) on file with the National Supplier Clearinghouse (NSC) before they submit a bid. Bids will be disqualified if a bidder does not meet all state licensure requirements for the applicable product categories and for every state in a CBA. Every supplier location is responsible for having all applicable license(s) for each state in which it provides services. For a multi-state CBA the bidder must collectively have all applicable license(s) for every state in the CBA. Each location is not required to have licenses for every state in the CBA as long as each state has a bidding location licensed for the product category.

See the CBIC website for a listing of CBAs.

“I understand that each supplier location is responsible for having all applicable state licenses for each state in which it provides services. Each location is not required to have licenses for every state in the CBA as long as there is a licensed location for each state.” 

* Some states may not require a license to furnish items in a specific product category. Please check the DMEPOS State License Directory on the NSC website and the Licensure for Bidding Suppliers fact sheet on the CBIC website to verify licensure requirements.

Supplier’s Legal Business Name Supplier’s Bidder No.

Section 2a. Location-Specific Questions

Please provide the requested information for each location in your business organization. You must provide the unique National Supplier Clearinghouse (NSC) Provider Transaction Access number (PTAN) that applies to each location. The NSC PTAN is hereafter referred to as PTAN. If you are bidding as a network, the primary network member should provide information for all its locations first.

H. Identifying Information

Provide the legal business name and mailing address for the network organization identified by the PTAN below.

Legal Network Name_____________________________________

Address Line 1___________________________________________________________________________________

(Street Name and Number)

Address Line 2___________________________________________________________________________________

(Suite, Room, etc.)

City/Town_________________________________________________ State__________________ Zip__________________

Telephone Number______________________ Toll Free Number___________________________

E-mail address:_________________________________

PTAN for this location_______________ NPI Identification Number______________

I. Physical Address

Is the supplier’s mailing address the same as the supplier’s physical address provided in Section 2a, Question H.?  Yes  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.)

City/Town_________________________________________________ State__________________ Zip__________________

J. Business Information

Provide the identifying information for the location as identified by the PTAN above in the identifying information question.

TIN Number______________

Doing Business As (DBA 1) ____________________________ Doing Business As (DBA 2) ____________________________

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

K. Type of Business

Select the type that describes this location as identified by the PTAN above. Bidders must submit certain financial documentation based on the type of business identified in this response. See the DMEPOS Competitive Bidding Program website at www.dmecompetitivebid.com/financialrequirements for further information.

 Corporation (LLC, Professional Corporation, S Corp and C Corp)  Municipality and State Owned  Other

 Sole Proprietorship  Partnership  Non-Profit Organization

L. Service Delivery

For the location identified above, how will service beneficiaries? (Check all that apply.)

 Retail Location  Home Delivery  Mail Order

Supplier’s Legal Business Name Supplier’s Bidder No.

M. Sanctions

Indicate whether this location, as identified by the PTAN above, has been subject to any current or past legal actions, or sanctions, such as debarments, with the past 5 years.

Does this location have any current or past legal actions, or sanctions such as debarments?  Yes  No

N. CBA and Product Category

You must associate this location with specific CBA/Product Category(s) where it will furnish items and services in order to be eligible to receive Medicare Payment for competitively bid items. Select the CBA(s)/product category(s) associated with this location.

Competitive Bidding Areas:

Cincinnati – Middletown (Ohio – Kentucky – Indiana)
Cleveland – Elyria – Mentor (Ohio)
Charlotte – Gastonia – Rock Hill (North Carolina – South Carolina)
Dallas – Fort Worth – Arlington (Texas)
Kansas City (Missouri – Kansas)
Miami – Fort Lauderdale – Pompano Beach (Florida)
Orlando – Kissimmee – Sanford (Florida)
Pittsburgh (Pennsylvania)
Riverside – San Bernardino – Ontario (California)

Product Categories:

Respiratory Equipment and Related Supplies and Accessories
Standard Mobility Equipment and Related Accessories
General Home Equipment and Related Supplies and Accessories
Enteral Nutrients, Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
External Infusion Pumps and Supplies

O. Add location

All locations that conduct business within a CBA and provide the product category for which you are bidding must be listed below. It is important that bidders identify all locations by PTAN that will provide competitively bid items in a CBA. Only those locations entered on the bid will be identified on the contract and be eligible to receive payment for the competitively bid item(s).

If you are bidding as a network, the primary network member should add its location first. If there are members of the network with multiple locations, the primary network member should add these members’ locations after the primary network member’s location.

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

Legal Business Name _________________________________ PTAN __________________________________

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (07/09) EFF (07/2009)