CMS-10169 CMS-10169.RFB Form A

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

Form Approved
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

If “None of the above”, briefly describe the supplier’s type of business.
____________________________________________________________________________________

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

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

C. Licensure
The bidder is responsible for having a copy of the applicable state license(s) on file in the Provider Enrollment Change and
Ownership System (PECOS) and 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.
For the national mail-order competition, the CBA includes all parts of the United States, including the 50 states, the District of
Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa; and the. The supplier must have all applicable
licenses needed to provide mail-order diabetic testing supplies throughout the entire CBA.
See the CBIC website for a listing of CBAs.
Do the locations included on your bid comply with the licensure requirements within the CBA for which you are bidding?
 Yes  No  N/A*
* 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.

D. Contact Person(s)
Person we should contact to answer questions regarding the business.
Contact Person(s) First Name__________________________ Last Name________________________ Title______________
(PRINT)
Telephone (include area code)_________________________ E-Mail Address_______________________________________

E. Authorized Official(s) or Key Personnel
Provide the name(s) and title(s) of the authorized official(s) or key personnel for the business organization.
Authorized Official(s) or Key Personnel:
First Name__________________________ Last Name________________________ Title______________
(PRINT)

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

F. Competitive Bidding Area (CBA) and Product Category
For Round 2 select all of the CBA(s) and product category(s) for which your business organization or network is submitting a
bid(s). If you are bidding in the national mail-order competition for diabetic testing supplies, select “National Mail-Order”.
Note: Networks are excluded from bidding in the national mail-order competition.

National Mail-Order
National Mail-Order

Round 2 Competitive Bidding Areas
Akron, OH

Memphis, TN-MS-AR

Albany-Schenectady-Troy, NY

Milwaukee-Waukesha-West Allis, WI

Albuquerque, NM

Minneapolis-St. Paul-Bloomington, MN-WI

Allentown-Bethlehem-Easton, PA-NJ

Nashville-Davidson-Murfreesboro-Franklin, TN

Asheville, NC

Nassau-Brooklyn-Queens, NY

Atlanta-Sandy Springs-Marietta, GA

New Haven-Milford, CT

Augusta-Richmond County, GA-SC

New Orleans-Metairie-Kenner, LA

Austin-Round Rock-San Marcos, TX

North Port-Bradenton-Sarasota, FL

Bakersfield-Delano, CA

Northern NYC Metro, NY

Baltimore-Towson, MD

Northern-Chicago Metro, IL-WI

Baton Rouge, LA

North-West NYC Metro, NJ

Beaumont-Port Arthur, TX

Ocala, FL

Birmingham-Hoover, AL

Oklahoma City, OK

Boise City-Nampa, ID

Omaha-Council Bluffs, NE-IA

Boston-Cambridge-Quincy, MA-NH

Orange County, CA

Bridgeport-Stamford-Norwalk, CT

Oxnard-Thousand Oaks-Ventura, CA

Bronx-Manhattan, NY

Palm Bay-Melbourne-Titusville, FL

Buffalo-Niagara Falls, NY

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

Cape Coral-Fort Myers, FL

Phoenix-Mesa-Glendale, AZ

Central Chicago Metro, IL

Portland-Vancouver-Hillsboro, OR-WA

Charleston-North Charleston-Summerville, SC

Poughkeepsie-Newburgh-Middletown, NY

Chattanooga, TN-GA

Providence-New Bedford-Fall River, RI-MA

Colorado Springs, CO

Raleigh-Cary, NC

Columbia, SC

Richmond, VA

Columbus, OH

Rochester, NY

Dayton, OH

Sacramento-Arden-Arcade-Roseville, CA

Deltona-Daytona Beach-Ormond Beach, FL

Salt Lake City, UT

Denver-Aurora-Broomfield, CO

San Antonio-New Braunfels, TX

Detroit-Warren-Livonia, MI

San Diego-Carlsbad-San Marcos, CA

El Paso, TX

San Francisco-Oakland-Fremont, CA

Flint, MI

San Jose-Sunnyvale-Santa Clara, CA

_________________________________________________________________________________________________________________________________________________

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

Fresno, CA

Scranton-Wilkes-Barre, PA

Grand Rapids-Wyoming, MI

Seattle-Tacoma-Bellevue, WA

Greensboro-High Point, NC

Southern NY Metro, NY-NJ

Greenville-Mauldin-Easley, SC

South West Chicago Metro, IL

Hartford-West Hartford-East Hartford, CT

Springfield, MA

Honolulu, HI

St. Louis, MO-IL

Houston-Sugar Land-Baytown, TX

Stockton, CA

Huntington-Ashland, WV-KY-OH

Suffolk, NY

Indiana-Chicago Metro, IN

Syracuse, NY

Indianapolis-Carmel, IN

Tampa-St. Petersburg-Clearwater, FL

Jackson, MS

Toledo, OH

Jacksonville, FL

Tucson, AZ

Knoxville, TN

Tulsa, OK

Lakeland-Winter Haven, FL

Virginia Beach-Norfolk-Newport News, VA-NC

Las Vegas-Paradise, NV

Visalia-Porterville, CA

Little Rock-North Little Rock-Conway, AR

Washington-Arlington-Alexandria, DC-VA-MD-WV

Los Angeles, CA

Wichita, KS

Louisville/Jefferson County, KY-IN

Worcester, MA

McAllen-Edinburg-Pharr, TX

Youngstown-Warren-Boardman, OH-PA

Round 2 Product Categories:
Oxygen Supplies and Equipment
Enteral Nutrients, Equipment and Supplies
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (Group 2 Mattresses and Overlays)
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories

_________________________________________________________________________________________________________________________________________________

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

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.

G. Identifying Information
Provide the legal business name, mailing address, and physical 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___________________________
Authorized Official E-mail address:_________________________________
PTAN (for this location)_______________NPI Number (for this location)______________

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
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

J. Type of Business
Select the type of business of this organization identified by the PTAN in Question G. 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 the Request for Bid (RFB) instructions for a list of required documents and checklist.
 Corporation (LLC, Professional Corporation, S Corp and C Corp)
 Sole Proprietorship
 Partnership

 Municipality and State Owned
 Non-Profit Organization

 Other

_________________________________________________________________________________________________________________________________________________

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

K. Service Delivery
How will this location provide competitively bid items and services to Medicare beneficiaries in a Round 2 CBA or in the National
Mail-Order CBA? (Check all that apply.)  Retail Location
 Home Delivery  Mail Order

L. 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

M. Accreditation
Identify the name of the Medicare-approved organization(s) that has accredited this location for the product category(s) for
which you are bidding.
Accrediting Organization __________________________________ Status __________________________________
Identify the product(s) for which you are accredited? __________________________________________________________
Indicate your accreditation issue date and expiration date:____________________
Issue Date (Month/Year)

________________________
Expiration Date (Month/Year)

N. Licensure
Identify the state(s) in the Round 2 CBA or national mail-order CBA in which you have a license to furnish the competitively bid
item(s):
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL

GA
HI
ID
IL
IN
IA
KS
KY
LA
ME

MD
MA
MI
MN
MS
MO
MT
NE
NV
NH

NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI

SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

PR
GU
AS
VI

O. CBA and Product Category
Select the CBA(s) for which this location will be servicing Medicare beneficiaries. You must associate this location with a specific
CBA and product category.

National Mail-Order
National Mail-Order

Round 2 Competitive Bidding Areas
Akron, OH

Memphis, TN-MS-AR

Albany-Schenectady-Troy, NY

Milwaukee-Waukesha-West Allis, WI

Albuquerque, NM

Minneapolis-St. Paul-Bloomington, MN-WI

Allentown-Bethlehem-Easton, PA-NJ

Nashville-Davidson-Murfreesboro-Franklin, TN

Asheville, NC

Nassau-Brooklyn-Queens, NY

Atlanta-Sandy Springs-Marietta, GA

New Haven-Milford, CT

Augusta-Richmond County, GA-SC

New Orleans-Metairie-Kenner, LA

Austin-Round Rock-San Marcos, TX

North Port-Bradenton-Sarasota, FL

_________________________________________________________________________________________________________________________________________________

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

Bakersfield-Delano, CA

Northern NYC Metro, NY

Baltimore-Towson, MD

Northern-Chicago Metro, IL-WI

Baton Rouge, LA

North-West NYC Metro, NJ

Beaumont-Port Arthur, TX

Ocala, FL

Birmingham-Hoover, AL

Oklahoma City, OK

Boise City-Nampa, ID

Omaha-Council Bluffs, NE-IA

Boston-Cambridge-Quincy, MA-NH

Orange County, CA

Bridgeport-Stamford-Norwalk, CT

Oxnard-Thousand Oaks-Ventura, CA

Bronx-Manhattan, NY

Palm Bay-Melbourne-Titusville, FL

Buffalo-Niagara Falls, NY

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

Cape Coral-Fort Myers, FL

Phoenix-Mesa-Glendale, AZ

Central Chicago Metro, IL

Portland-Vancouver-Hillsboro, OR-WA

Charleston-North Charleston-Summerville, SC

Poughkeepsie-Newburgh-Middletown, NY

Chattanooga, TN-GA

Providence-New Bedford-Fall River, RI-MA

Colorado Springs, CO

Raleigh-Cary, NC

Columbia, SC

Richmond, VA

Columbus, OH

Rochester, NY

Dayton, OH

Sacramento-Arden-Arcade-Roseville, CA

Deltona-Daytona Beach-Ormond Beach, FL

Salt Lake City, UT

Denver-Aurora-Broomfield, CO

San Antonio-New Braunfels, TX

Detroit-Warren-Livonia, MI

San Diego-Carlsbad-San Marcos, CA

El Paso, TX

San Francisco-Oakland-Fremont, CA

Flint, MI

San Jose-Sunnyvale-Santa Clara, CA

Fresno, CA

Scranton-Wilkes-Barre, PA

Grand Rapids-Wyoming, MI

Seattle-Tacoma-Bellevue, WA

Greensboro-High Point, NC

Southern NY Metro, NY-NJ

Greenville-Mauldin-Easley, SC

South West Chicago Metro, IL

Hartford-West Hartford-East Hartford, CT

Springfield, MA

Honolulu, HI

St. Louis, MO-IL

Houston-Sugar Land-Baytown, TX

Stockton, CA

Huntington-Ashland, WV-KY-OH

Suffolk, NY

Indiana-Chicago Metro, IN

Syracuse, NY

Indianapolis-Carmel, IN

Tampa-St. Petersburg-Clearwater, FL

Jackson, MS

Toledo, OH

Jacksonville, FL

Tucson, AZ

Knoxville, TN

Tulsa, OK

Lakeland-Winter Haven, FL

Virginia Beach-Norfolk-Newport News, VA-NC

Las Vegas-Paradise, NV

Visalia-Porterville, CA

Little Rock-North Little Rock-Conway, AR

Washington-Arlington-Alexandria, DC-VA-MD-WV

Los Angeles, CA

Wichita, KS

Louisville/Jefferson County, KY-IN

Worcester, MA

McAllen-Edinburg-Pharr, TX

Youngstown-Warren-Boardman, OH-PA

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

Round 2 Product Categories:
Oxygen Supplies and Equipment
Enteral Nutrients, Equipment and Supplies
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (Group 2 Mattresses and Overlays)
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories

P. Add location
All locations that provide or will provide the product category in a Round 2 CBA or national mail-order CBA 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 in Round 2, 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
Legal Business Name
Legal Business Name
Legal Business Name
Legal Business Name
Legal Business Name
Legal Business Name

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

PTAN
PTAN
PTAN
PTAN
PTAN
PTAN
PTAN

__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

Section 1b. Additional Locations
Location-Specific Questions
Provide the legal business name and mailing address for the location identified by PTAN below. Important Note: The PTAN
identified in this section must correspond with the location being identified in this section.

G. Identifying Information
Provide the legal business name, mailing address, and physical address for the business 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___________________________
Authorized Official E-mail address:_________________________________
PTAN (for this location)_______________NPI Number (for this location)______________

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
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

J. Type of Business
Select the type of business for this organization identified by the PTAN in Question N. 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 the Request for Bid (RFB) instructions for a list of required documents and checklist.
 Corporation (LLC, Professional Corporation, S Corp and C Corp)
 Sole Proprietorship
 Partnership

 Municipality and State Owned
 Non-Profit Organization

 Other

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

K. Service Delivery
How will this location provide competitively bid items and services to Medicare beneficiaries in a Round 2 CBA or in the National
Mail-Order CBA? (Check all that apply.)  Retail Location
 Home Delivery  Mail Order

L. 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

M. Accreditation
Identify the name of the Medicare-approved organization(s) that has accredited this location for the product category in which
you are bidding.
Accrediting Organization __________________________________ Status __________________________________
For which product specific area(s) are you accredited? __________________________________________________________
Indicate your accreditation issue date and expiration date:____________________
Issue Date (Month/Year)

________________________
Expiration Date (Month/Year)

N. Licensure
Identify the state(s) in the Round 2 CBA or national mail-order CBA in which you have a license to furnish the competitively bid
item(s):
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL

GA
HI
ID
IL
IN
IA
KS
KY
LA
ME

MD
MA
MI
MN
MS
MO
MT
NE
NV
NH

NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI

SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

PR
GU
AS
VI

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

O. CBA and Product Category
Select the CBA(s) for which this location will be servicing Medicare beneficiaries. You must associate this location with a specific
CBA and product category.

National Mail-Order
National Mail-Order

Round 2 Competitive Bidding Areas
Akron, OH

Memphis, TN-MS-AR

Albany-Schenectady-Troy, NY

Milwaukee-Waukesha-West Allis, WI

Albuquerque, NM

Minneapolis-St. Paul-Bloomington, MN-WI

Allentown-Bethlehem-Easton, PA-NJ

Nashville-Davidson-Murfreesboro-Franklin, TN

Asheville, NC

Nassau-Brooklyn-Queens, NY

Atlanta-Sandy Springs-Marietta, GA

New Haven-Milford, CT

Augusta-Richmond County, GA-SC

New Orleans-Metairie-Kenner, LA

Austin-Round Rock-San Marcos, TX

North Port-Bradenton-Sarasota, FL

Bakersfield-Delano, CA

Northern NYC Metro, NY

Baltimore-Towson, MD

Northern-Chicago Metro, IL-WI

Baton Rouge, LA

North-West NYC Metro, NJ

Beaumont-Port Arthur, TX

Ocala, FL

Birmingham-Hoover, AL

Oklahoma City, OK

Boise City-Nampa, ID

Omaha-Council Bluffs, NE-IA

Boston-Cambridge-Quincy, MA-NH

Orange County, CA

Bridgeport-Stamford-Norwalk, CT

Oxnard-Thousand Oaks-Ventura, CA

Bronx-Manhattan, NY

Palm Bay-Melbourne-Titusville, FL

Buffalo-Niagara Falls, NY

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

Cape Coral-Fort Myers, FL

Phoenix-Mesa-Glendale, AZ

Central Chicago Metro, IL

Portland-Vancouver-Hillsboro, OR-WA

Charleston-North Charleston-Summerville, SC

Poughkeepsie-Newburgh-Middletown, NY

Chattanooga, TN-GA

Providence-New Bedford-Fall River, RI-MA

Colorado Springs, CO

Raleigh-Cary, NC

Columbia, SC

Richmond, VA

Columbus, OH

Rochester, NY

Dayton, OH

Sacramento-Arden-Arcade-Roseville, CA

Deltona-Daytona Beach-Ormond Beach, FL

Salt Lake City, UT

Denver-Aurora-Broomfield, CO

San Antonio-New Braunfels, TX

Detroit-Warren-Livonia, MI

San Diego-Carlsbad-San Marcos, CA

El Paso, TX

San Francisco-Oakland-Fremont, CA

Flint, MI

San Jose-Sunnyvale-Santa Clara, CA

Fresno, CA

Scranton-Wilkes-Barre, PA

Grand Rapids-Wyoming, MI

Seattle-Tacoma-Bellevue, WA

_________________________________________________________________________________________________________________________________________________

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

Greensboro-High Point, NC

Southern NY Metro, NY-NJ

Greenville-Mauldin-Easley, SC

South West Chicago Metro, IL

Hartford-West Hartford-East Hartford, CT

Springfield, MA

Honolulu, HI

St. Louis, MO-IL

Houston-Sugar Land-Baytown, TX

Stockton, CA

Huntington-Ashland, WV-KY-OH

Suffolk, NY

Indiana-Chicago Metro, IN

Syracuse, NY

Indianapolis-Carmel, IN

Tampa-St. Petersburg-Clearwater, FL

Jackson, MS

Toledo, OH

Jacksonville, FL

Tucson, AZ

Knoxville, TN

Tulsa, OK

Lakeland-Winter Haven, FL

Virginia Beach-Norfolk-Newport News, VA-NC

Las Vegas-Paradise, NV

Visalia-Porterville, CA

Little Rock-North Little Rock-Conway, AR

Washington-Arlington-Alexandria, DC-VA-MD-WV

Los Angeles, CA

Wichita, KS

Louisville/Jefferson County, KY-IN

Worcester, MA

McAllen-Edinburg-Pharr, TX

Youngstown-Warren-Boardman, OH-PA

Round 2 Product Categories:
Oxygen Supplies and Equipment
Enteral Nutrients, Equipment and Supplies
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (Group 2 Mattresses and Overlays)
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories

_________________________________________________________________________________________________________________________________________________

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

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
Do the Network Members have a signed legal contract?  Yes  No
Network Name_____________________________________________________

B. Specialty Supplier
Are you a Skilled Nursing Facility (SNF) or a 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. Licensure
The bidder is responsible for having a copy of the applicable state license(s) on file in the Provider Enrollment Change and
Ownership System (PECOS) and 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.
Do the locations included on your bid comply with the licensure requirements within the CBA for which you are bidding?
 Yes  No  N/A*
* Some areas may not require a license to furnish items in a specific product category. Please check with the licensing
agency for requirements.

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

D. Contact Person(s)
Contact Person(s) First Name__________________________ Last Name________________________ Title______________
(PRINT)
Telephone (include area code)_________________________ E-Mail Address_______________________________________

E. Authorized Official(s) or Key Personnel
Provide the name(s) and title(s) of the authorized official(s) or key personnel for the business organization.
Authorized Official(s) or Key Personnel
First Name__________________________ Last Name________________________ Title______________
(PRINT)

F. Competitive Bidding Area (CBA) and Product Category
For Round 2 select all of the CBA(s) and product category(s) for which your business organization or network is submitting a
bid(s):
Note: Networks are excluded from bidding in the national mail-order competition.

Round 2 Competitive Bidding Areas
Akron, OH

Memphis, TN-MS-AR

Albany-Schenectady-Troy, NY

Milwaukee-Waukesha-West Allis, WI

Albuquerque, NM

Minneapolis-St. Paul-Bloomington, MN-WI

Allentown-Bethlehem-Easton, PA-NJ

Nashville-Davidson-Murfreesboro-Franklin, TN

Asheville, NC

Nassau-Brooklyn-Queens, NY

Atlanta-Sandy Springs-Marietta, GA

New Haven-Milford, CT

Augusta-Richmond County, GA-SC

New Orleans-Metairie-Kenner, LA

Austin-Round Rock-San Marcos, TX

North Port-Bradenton-Sarasota, FL

Bakersfield-Delano, CA

Northern NYC Metro, NY

Baltimore-Towson, MD

Northern-Chicago Metro, IL-WI

Baton Rouge, LA

North-West NYC Metro, NJ

Beaumont-Port Arthur, TX

Ocala, FL

Birmingham-Hoover, AL

Oklahoma City, OK

Boise City-Nampa, ID

Omaha-Council Bluffs, NE-IA

Boston-Cambridge-Quincy, MA-NH

Orange County, CA

Bridgeport-Stamford-Norwalk, CT

Oxnard-Thousand Oaks-Ventura, CA

Bronx-Manhattan, NY

Palm Bay-Melbourne-Titusville, FL

Buffalo-Niagara Falls, NY

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

Cape Coral-Fort Myers, FL

Phoenix-Mesa-Glendale, AZ

Central Chicago Metro, IL

Portland-Vancouver-Hillsboro, OR-WA

Charleston-North Charleston-Summerville, SC

Poughkeepsie-Newburgh-Middletown, NY

Chattanooga, TN-GA

Providence-New Bedford-Fall River, RI-MA

Colorado Springs, CO

Raleigh-Cary, NC

Columbia, SC

Richmond, VA

Columbus, OH

Rochester, NY

Dayton, OH

Sacramento-Arden-Arcade-Roseville, CA

_________________________________________________________________________________________________________________________________________________

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

Deltona-Daytona Beach-Ormond Beach, FL

Salt Lake City, UT

Denver-Aurora-Broomfield, CO

San Antonio-New Braunfels, TX

Detroit-Warren-Livonia, MI

San Diego-Carlsbad-San Marcos, CA

El Paso, TX

San Francisco-Oakland-Fremont, CA

Flint, MI

San Jose-Sunnyvale-Santa Clara, CA

Fresno, CA

Scranton-Wilkes-Barre, PA

Grand Rapids-Wyoming, MI

Seattle-Tacoma-Bellevue, WA

Greensboro-High Point, NC

Southern NY Metro, NY-NJ

Greenville-Mauldin-Easley, SC

South West Chicago Metro, IL

Hartford-West Hartford-East Hartford, CT

Springfield, MA

Honolulu, HI

St. Louis, MO-IL

Houston-Sugar Land-Baytown, TX

Stockton, CA

Huntington-Ashland, WV-KY-OH

Suffolk, NY

Indiana-Chicago Metro, IN

Syracuse, NY

Indianapolis-Carmel, IN

Tampa-St. Petersburg-Clearwater, FL

Jackson, MS

Toledo, OH

Jacksonville, FL

Tucson, AZ

Knoxville, TN

Tulsa, OK

Lakeland-Winter Haven, FL

Virginia Beach-Norfolk-Newport News, VA-NC

Las Vegas-Paradise, NV

Visalia-Porterville, CA

Little Rock-North Little Rock-Conway, AR

Washington-Arlington-Alexandria, DC-VA-MD-WV

Los Angeles, CA

Wichita, KS

Louisville/Jefferson County, KY-IN

Worcester, MA

McAllen-Edinburg-Pharr, TX

Youngstown-Warren-Boardman, OH-PA

Round 2 Product Categories:
Oxygen Supplies and Equipment
Enteral Nutrients, Equipment and Supplies
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (Group 2 Mattresses and Overlays)
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

Section 2a. Location-Specific Questions
Provide the legal business name and mailing address for the location identified by PTAN below. Important Note: The PTAN
identified in this section must correspond with the location being identified in this section.

G. Identifying Information
Provide the legal business name, mailing address, and physical address for the business 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___________________________
Authorized Official E-mail address:_________________________________
PTAN (for this location)_______________NPI Number (for this location)______________

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
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

J. Type of Business
Select the business type of this organization identified by the PTAN in Question G. 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 the Request for Bid (RFB) instructions for a list of required documents and checklist.
 Corporation (LLC, Professional Corporation, S Corp and C Corp)
 Sole Proprietorship
 Partnership

 Municipality and State Owned
 Non-Profit Organization

 Other

K. Service Delivery
How will this location provide competitively bid items and services to Medicare beneficiaries in a Round 2 CBA or in the National
Mail-Order CBA? (Check all that apply.)  Retail Location
 Home Delivery  Mail Order

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

L. 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

M. Accreditation
Identify the name of the Medicare-approved organization(s) that has accredited this location for the product category in which
you are bidding.
Accrediting Organization __________________________________ Status __________________________________
For which product specific area(s) are you accredited? __________________________________________________________
Indicate your accreditation issue date and expiration date:____________________
Issue Date (Month/Year)

________________________
Expiration Date (Month/Year)

N. Licensure
Identify the state(s) in the Round 2 CBA in which you have a license to furnish the competitively bid item(s):

AL
AR
AZ
CA
CO
CT
DC
DE

FL
GA
HI
IA
ID
IL
IN
KS

KY
LA
MA
MD
MI
MN
MO
MS

NC
NE
NH
NJ
NM
NV
NY
OH

OK
OR
PA
RI
SC
TN
TX
UT

VA
WA
WI
WV

_________________________________________________________________________________________________________________________________________________

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

Supplier’s Legal Business Name

Supplier’s Bidder No.

O. CBA and Product Category
For Round 2 select all of the CBA(s) and product category(s) for which your business organization or network is submitting a
bid(s).
Note: Networks are excluded from bidding in the national mail-order competition.

Round 2 Competitive Bidding Areas
Akron, OH

Memphis, TN-MS-AR

Albany-Schenectady-Troy, NY

Milwaukee-Waukesha-West Allis, WI

Albuquerque, NM

Minneapolis-St. Paul-Bloomington, MN-WI

Allentown-Bethlehem-Easton, PA-NJ

Nashville-Davidson-Murfreesboro-Franklin, TN

Asheville, NC

Nassau-Brooklyn-Queens, NY

Atlanta-Sandy Springs-Marietta, GA

New Haven-Milford, CT

Augusta-Richmond County, GA-SC

New Orleans-Metairie-Kenner, LA

Austin-Round Rock-San Marcos, TX

North Port-Bradenton-Sarasota, FL

Bakersfield-Delano, CA

Northern NYC Metro, NY

Baltimore-Towson, MD

Northern-Chicago Metro, IL-WI

Baton Rouge, LA

North-West NYC Metro, NJ

Beaumont-Port Arthur, TX

Ocala, FL

Birmingham-Hoover, AL

Oklahoma City, OK

Boise City-Nampa, ID

Omaha-Council Bluffs, NE-IA

Boston-Cambridge-Quincy, MA-NH

Orange County, CA

Bridgeport-Stamford-Norwalk, CT

Oxnard-Thousand Oaks-Ventura, CA

Bronx-Manhattan, NY

Palm Bay-Melbourne-Titusville, FL

Buffalo-Niagara Falls, NY

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

Cape Coral-Fort Myers, FL

Phoenix-Mesa-Glendale, AZ

Central Chicago Metro, IL

Portland-Vancouver-Hillsboro, OR-WA

Charleston-North Charleston-Summerville, SC

Poughkeepsie-Newburgh-Middletown, NY

Chattanooga, TN-GA

Providence-New Bedford-Fall River, RI-MA

Colorado Springs, CO

Raleigh-Cary, NC

Columbia, SC

Richmond, VA

Columbus, OH

Rochester, NY

Dayton, OH

Sacramento-Arden-Arcade-Roseville, CA

Deltona-Daytona Beach-Ormond Beach, FL

Salt Lake City, UT

Denver-Aurora-Broomfield, CO

San Antonio-New Braunfels, TX

Detroit-Warren-Livonia, MI

San Diego-Carlsbad-San Marcos, CA

El Paso, TX

San Francisco-Oakland-Fremont, CA

Flint, MI

San Jose-Sunnyvale-Santa Clara, CA

Fresno, CA

Scranton-Wilkes-Barre, PA

Grand Rapids-Wyoming, MI

Seattle-Tacoma-Bellevue, WA

Greensboro-High Point, NC

Southern NY Metro, NY-NJ

Greenville-Mauldin-Easley, SC

South West Chicago Metro, IL

_________________________________________________________________________________________________________________________________________________

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

Hartford-West Hartford-East Hartford, CT

Springfield, MA

Honolulu, HI

St. Louis, MO-IL

Houston-Sugar Land-Baytown, TX

Stockton, CA

Huntington-Ashland, WV-KY-OH

Suffolk, NY

Indiana-Chicago Metro, IN

Syracuse, NY

Indianapolis-Carmel, IN

Tampa-St. Petersburg-Clearwater, FL

Jackson, MS

Toledo, OH

Jacksonville, FL

Tucson, AZ

Knoxville, TN

Tulsa, OK

Lakeland-Winter Haven, FL

Virginia Beach-Norfolk-Newport News, VA-NC

Las Vegas-Paradise, NV

Visalia-Porterville, CA

Little Rock-North Little Rock-Conway, AR

Washington-Arlington-Alexandria, DC-VA-MD-WV

Los Angeles, CA

Wichita, KS

Louisville/Jefferson County, KY-IN

Worcester, MA

McAllen-Edinburg-Pharr, TX

Youngstown-Warren-Boardman, OH-PA

Round 2 Product Categories:
Oxygen Supplies and Equipment
Enteral Nutrients, Equipment and Supplies
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (Group 2 Mattresses and Overlays)
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories

G. Add location
All locations that conduct business within a Round 2 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 in Round 2, 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
Legal Business Name
Legal Business Name
Legal Business Name
Legal Business Name

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

PTAN
PTAN
PTAN
PTAN
PTAN

__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

_________________________________________________________________________________________________________________________________________________

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