Information Collection

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)

IC 203537 under ICR 201207-0938-007 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)	Form and Instruction
CMS-10169 Application for Suppliers Form A_ 2012 30-day notice.docx	Form and Instruction
CMS-10169.Crosswalks for Form A.xlsx Crosswalk for Application	IC Document
1 Network Business Org Screen View.JPG Network Business Organization Screen Shot	IC Document
1-Business Org Screen View.JPG Business Organization Screenshot	IC Document
2-Location Specific Information Screen View.JPG Location Specific Screenshot	IC Document
3-CBAs and Product Categories Screen View.JPG CBAs and Product Category Screenshot	IC Document
4-add location Screen View.JPG Add location screenshot	IC Document
5-additional locations Screen View.JPG Additional locations screenshot	IC Document
6-cbas and product categories Screen View.JPG CBAs and Product Categories	IC Document

IC Title:

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.410

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10169	Application for Suppliers	Form A_ 2012 30-day notice.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,011

Number of Respondents for Small Entity: 708

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	337	337
Annual IC Time Burden (Hours)	2,696	2,696
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk for Application	CMS-10169.Crosswalks for Form A.xlsx	07/25/2012
Network Business Organization Screen Shot	1 Network Business Org Screen View.JPG	07/25/2012
Business Organization Screenshot	1-Business Org Screen View.JPG	07/25/2012
Location Specific Screenshot	2-Location Specific Information Screen View.JPG	07/25/2012
CBAs and Product Category Screenshot	3-CBAs and Product Categories Screen View.JPG	07/25/2012
Add location screenshot	4-add location Screen View.JPG	07/25/2012
Additional locations screenshot	5-additional locations Screen View.JPG	07/25/2012
CBAs and Product Categories	6-cbas and product categories Screen View.JPG	07/25/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.