Information Collection

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

IC 203537 under ICR 201305-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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: Removed

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.410

Information Collection 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 %

	Program Change Due to Agency Discretion	Previously Approved
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

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.