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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10169 Application for Suppliers 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: Removed

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				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
	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

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk for Application		07/25/2012
Network Business Organization Screen Shot		07/25/2012
Business Organization Screenshot		07/25/2012
Location Specific Screenshot		07/25/2012
CBAs and Product Category Screenshot		07/25/2012
Add location screenshot		07/25/2012
Additional locations screenshot		07/25/2012
CBAs and Product Categories		07/25/2012

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

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