Information Collection Request

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

ICR 201407-0938-008 · OMB 0938-1016 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10169 Form B _ Bidding Form Form and Instruction New Available
Form CMS-10169 Form A - Application for DMEPOS Competitive Bidding Program Form and Instruction New Available
Form CMS-10169 Change of Ownership - Purchaser Form - 30-day notice Form and Instruction Modified Available
Form CMS-10169 Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice Form and Instruction Modified Available
Form CMS-10169 Contract Suppliers Disclosure of Subcontractors Form and Instruction Modified Available
Form CMS-10169 Beneficiary Survey (Spanish Language Version) Form and Instruction Modified Available
Form CMS-10169 Beneficiary Survey (English Language Version) Form and Instruction Modified Available
Form CMS-10169 Quarterly Report Form and Instruction Modified Available
508_Crosswalk for Form B PRA 6-30-14.pdf Supplementary Document Uploaded 2014-07-07 Available
508_Crosswalk for Form A PRA 6-30-14.pdf Supplementary Document Uploaded 2014-07-07 Available
508_CMS-10169_Supporting_Statement_Part_A.docx Supporting Statement A Uploaded 2014-07-07 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
212257 Bidding Form (Form B) Form and Instruction NewForm B _ Bidding Form
212256 Application for DMEPOS Competitve Bidding Program (Form A) Form and Instruction NewForm A - Application for DMEPOS Competitive Bidding Program
206873 Change of Ownership (CHOW) - Purchaser Form Form and Instruction ModifiedChange of Ownership - Purchaser Form - 30-day notice
206872 Change of Ownership (CHOW) Contract Supplier Notification Form Form and Instruction ModifiedChange of Ownership - Contract Supplier Notificaiton Form - 60-day Notice
203541 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure Form and Instruction ModifiedContract Suppliers Disclosure of Subcontractors
203540 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction ModifiedBeneficiary Survey (Spanish Language Version)
203540 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction ModifiedBeneficiary Survey (English Language Version)
203539 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) Form and Instruction ModifiedQuarterly Report

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2017 36 Months From Approved 06/30/2016
39,455 0 20,212
235,014 0 9,301
0 0 0





Reginfo record details
7
table that charts list of burden
IC Title Form No. Form Name
Application for DMEPOS Competitve Bidding Program (Form A) CMS-10169
Bidding Form (Form B) CMS-10169
Change of Ownership (CHOW) - Purchaser Form CMS-10169
Change of Ownership (CHOW) Contract Supplier Notification Form CMS-10169
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) CMS-10169
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure CMS-10169
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) CMS-10169, CMS-10169 ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 39,455 20,212 19,243 0 0 0
Annual Time Burden (Hours) 235,014 9,301 225,713 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No