| MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM FORM A: APPLICATIONS FOR DMEPOS COMPETITIVE BIDDING PROGRAM SECTION 1: APPLICATION FOR SUPPLIERS/NETWORKS |
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| Current OMB Approved Form Posted for 60-Day Notice | Updated Form Approval Request | ||||||||
| Row | Topic | Section | Page | Item # | Section | Page | Item # | Comments | |
| 1 | Business Organization Information | 1 | 1 | A | 1 | 1 | A | Removed statement to describe "None of the above". Information obtained from other sources. | |
| 2 | Specialty Supplier | 1 | 1 | B | 1 | 1 | B | No change. | |
| 3 | Licensure | 1 | 1 | C | 1 | 3 | G | Relocated question. Rephrased licensure attestation for clarity. | |
| 4 | Contact Person(s) | 1 | 2 | D | 1 | 1 | 1 | C | Relocated question. Descriptive language added to clarify the question. |
| 5 | Authorized Official(s) or Key Personnel | 1 | 2 | E | 1 | 2 | D | No change. Question renumbered. | |
| 6 | CBA / PC | 1 | 2 | F | 1 | 2 | E | No change. Question renumbered. | |
| Location-Specific Questions | |||||||||
| 7 | Identifying Information | 1 | 4 | G | 1 | 4 | H | 1) Removed "physical address"; information addressed in next question. 2)Removed "Authorized Official" from email address request. 3) Added "Identification" to NPI for clarity. | |
| 8 | Physical Address | 1 | 4 | H | 1 | 4 | I | No change. Question renumbered. | |
| 9 | Business Information | 1 | 4 | I | 1 | 4 | J | No change. Question renumbered. | |
| 10 | Type of Business | 1 | 4 | J | 1 | 4 | K | Removed comment "If 'Other', briefly describe the supplier's type of business". Question renumbered. | |
| 11 | Service Delivery | 1 | 4 | K | 1 | 4 | L | No change. Question renumbered. | |
| 12 | Sanctions | 1 | 5 | L | 1 | 5 | M | No change. Question renumbered. | |
| 13 | Accreditation | 1 | 4 | M | 1 | 2 | F | Relocated accreditation question. Question will be asked at the organization level only. | |
| 14 | Licensure | 1 | 5 | N | Removed question. Information obtained through attestation at the organization level. | ||||
| 15 | CBA / PC | 1 | 5 | O | 1 | 5 | N | Clarifying language added to sentence. Question renumbered. | |
| Additional Locations | |||||||||
| 16 | Identifying Information | 1 | 7 | G | 1 | 6 | G | 1) Removed "physical address"; information addressed in next question. 2)Removed "Authorized Official" from email address request. 3) Added "Identification" to NPI for clarity. 4) Re-structured sentences for clarity | |
| 17 | Physical Address | 1 | 7 | H | 1 | 6 | H | No change. | |
| 18 | Business Information | 1 | 7 | I | 1 | 6 | I | No change. | |
| 19 | Type of Business | 1 | 7 | J | Question removed, information obtained at the organization level. | ||||
| 20 | Service Delivery | 1 | 7 | K | Question removed, information obtained at the organization level. | ||||
| 21 | Sanctions | 1 | 8 | L | 1 | 6 | J | No change. Question renumbered. | |
| 22 | Accreditation | 1 | 8 | M | Question removed, information obtained at the organization level. | ||||
| 23 | Licensure | 1 | 8 | N | Removed question. Information obtained through attestation at the organization level. | ||||
| 24 | CBA / PC | 1 | 8 | O | 1 | 7 | K | 1) Removed "physical address"; information addressed in next question. 2)Removed "Authorized Official" from email address request. 3) Added "Identification" to NPI for clarity. 4) Re-structured sentences for clarity | |
| NOTE: Section 2 for network suppliers contains the same questions as Section 1 so the changes are made in Section 1 will also apply to Section 2. The only exception is for the following question: | |||||||||
| 25 | Business Organization Information | 2 | 9 | A | 2 | 8 | A | Restated question regarding network agreement for clarity. | |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |