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

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

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.