Information Collection

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)

IC 203538 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⚠️ Notice: This information collection may be referencing outdated material.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 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)	Form and Instruction
CMS-10169 Form B - Bidding Form Form B_2012.docx	Form and Instruction
Form B-1.jpg Furnished Items screenshot	IC Document
Form B-2.jpg Expansion screenshot	IC Document
Form B-3.jpg Bid Select screenshot	IC Document
Form B-4.jpg Manufacturer screenshot	IC Document
Form B-5.jpg Bid (Certification) screenshot	IC Document
Form B-6.jpg Public Address Announcement screenshot	IC Document

IC Title:

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)

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	Form B - Bidding Form	Form B_2012.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: 0 %

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)	-24,264	24,264
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Furnished Items screenshot	Form B-1.jpg	07/25/2012
Expansion screenshot	Form B-2.jpg	07/25/2012
Bid Select screenshot	Form B-3.jpg	07/25/2012
Manufacturer screenshot	Form B-4.jpg	07/25/2012
Bid (Certification) screenshot	Form B-5.jpg	07/25/2012
Public Address Announcement screenshot	Form B-6.jpg	07/25/2012

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