Form CMS-10169 CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS

SAMPLE FORM: This form is being provided as .a sample for contract suppliers to disclose information on their subcontracting arrangements to the
Centers for Medicare & Medica1d Serv1ces (Cf\o1S).

CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS
Consistent with Article VI of the Supplier Contr act, provide the information below for each subcontractor(s). The Authorized Official must disclose to
the Center s for tv1edicare & fvledicaid Services ( CMS) information on each subcontr acting r elationship that the contract supplier has enter ed into to
furnish items and services under its contract and whether each subcontractor meets the accr editation r equir ements in 42 CFR 424.57, if applicable.
This information must be provided within 10 business days after final contr.act execution . For subcontr acting arrangements enter ed into after contr act
awar d, the required disclosur es must occur no later than 10 business days after the date the contract supplier enters into a subcontracting
arrangement. Please visit the Competitive Bidding Implementation Contractor (CBIC) website at www.dmecompetitivebid .com for information
r egarding applicable accr editation r equir ements for subcontr actor s.
Please provide the following information for the contract supplier :

* - denotes requir ed

fields

Provide the following information for each subcontractor:
Doing Business As Name

legal Business Name*

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Provide the address of the particular location that wi/J perform
th e subcontracting service(s) .
Corporate headquarters' addresses are not acceptable.
Address line 1 *

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Same as Legal Business Name

Addres.s line 2

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State*

City"'

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ZIP Code*

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Phone Number:*

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Type of Subcontractor Service (Select a ll that apply)*
Meets Accreditation Requirements, if applicable

Hold CTRL key a nd click to select multiples

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Delivery
Instruction
Purchase of lnvenlory
Repair of Rented Equipment

Yes

0 No

Pl ease note: This only applies to Instruction and will only
appear for Instruction.

*L\lPORTA.'ll:
t If the subcontractor is required to be. accredited, you musts ubmit a copy of the. ac.c reditation certificate ro the CBIC.
Please note: This only applies to Instruction and will only appear for Instruction.

Does this apply to multiple contracts?

r

Yes

r

No

Contract Number*
(Check your contraet(s) for the contract number.)

I12'El - !123455 7
CBA (Select all that apply)*

Product Category

I<- SELECT PRODUCT CATEGORY->

Charlotte-Gastonia-Concord, NC-SC
Cincinnati-Middletown, OH-KY-IN
Cleveland-Elyria-Mentor, OH
Dallas-Fort-Worth-Arlington, TX
Kansas City, MO-KS
Miami-Fourt Lauderdale-Pompano Beach, FL

.!.
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Contract Number

Product Category

Competitive Bidding Areas

Oxygen Supplies and Equipment

Charlotte-Gastonia-Concord, NC
Dallas-Fort Worth-Arlington, TX
Kansas City, MO-KS

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12-1234567

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Type

Contract

Product Categories

Competitive Bidding Areas

Add Subcontractor

12-1234567

Oxygen Supplies and
Equipment

Charlotte-Gastonia-Concord, NC
Dallas-Fort Worth-Arlington, TX
Kansas City, MO-KS

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