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

Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

OMB: 0938-1016

IC ID: 203537

Information Collection (IC) Details

View Information Collection (IC)

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)
 
No Removed
 
Mandatory
 
42 CFR 414.410

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

Health Health Care Services

 

1,011 708
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 -337 0 0 337
Annual IC Time Burden (Hours) 0 0 -2,696 0 0 2,696
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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