Information Collection

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure

IC 203541 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⚠️ Notice: This information collection may be referencing outdated material.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; Subcontracting Disclosure	Form and Instruction
CMS-10169 CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS Subcontracting screenshot FINAL.PDF	Form and Instruction
Crosswalk for Changes to Subcontracting Form.docx Crosswalk -- CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS	IC Document

IC Title:

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.422(f)

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	CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS	Subcontracting screenshot FINAL.PDF		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 390

Number of Respondents for Small Entity: 273

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	390	290	100
Annual IC Time Burden (Hours)	160	132	28
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk -- CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS	Crosswalk for Changes to Subcontracting Form.docx	05/10/2013

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