Form CMS-10169 Form A - Application for DMEPOS Competitive Bidding Prog

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Fo rm Approved

OMB No. 0938-1016

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
For CMS Use Only
Bidder No.

Date Application Received

Competitive Bidding Area (CBA)

Bidder’s Identifying Information
Bidder’s Legal Business Name

Primary Bidder’s Legal Business Name (if network)

FORM A: APPLICATION FOR DMEPOS COMPETITIVE BIDDING PROGRAM
Please read all instructions completely. Suppliers with a single location or multiple locations must complete Sections
1 (Application for Suppliers) and 1a (Location Specific Questions). Multiple location suppliers must also complete
Section 1b (Location Specific Questions – Additional Locations) for each additional location. Networks must complete
Section 2; do not complete any part of Section 1.

Section 1: Application for Suppliers
A. Business Organization Information
Legal Business Name
Indicate how your business organization will be bidding (choose only one option).




Supplier with a Single Location (Complete Section 1-1a)
Supplier with Multiple Locations (Complete Section 1,1a, & 1b)
Network (Complete Section 2-2a)

If you selected “Supplier with Multiple Locations,” select one of the following that best describes your business
organization structure.






Subsidiary of a parent company/holding company
Commonly owned or commonly controlled
National Chain
Franchise
None of the above

If “None of the above,” briefly describe the supplier’s type of business.

B. Specialty Supplier
Is your organization a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) that is bidding as a specialty supplier and
plans to furnish competitively bid items only to its own residents?
 Yes  No

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

C. Contact Person
Provide the name(s) of the person(s) who should be contacted to answer questions regarding the business
organization.
Contact Person(s): First Name
E-Mail Address

Last Name

Title

Telephone (include area code)

D. Authorized Official or Key Personnel
Provide the name(s) and title(s) of the authorized official(s) or key personnel for the business organization.
Key Personnel: First Name

Last Name

Title

E. Accreditation
By the close of the bid window, all locations must meet Medicare enrollment requirements, including being accredited for all
items in the product category(s) for which the bidder is submitting a bid. As required by 42 CFR § 414.414, each bidder must be
enrolled, meet quality standards, and be accredited in order to be awarded a contract. Individual locations of a supplier with
multiple locations must separately meet these requirements to be included in a contract offer.
Identify the name(s) of the Medicare-approved organization(s) that has accredited your business organization for the
product category(s) in which you are bidding.
Accrediting Organization
I acknowledge and understand that I, as a bidder, must be properly accredited to furnish the specific item(s) and
service(s) included in the bid. This information must be on file in each location’s Medicare enrollment record (i.e.,
Provider Enrollment, Chain and Ownership System (PECOS))  Yes

F. Licensure
By the close of the bid window, all locations must meet Medicare enrollment requirements, including possessing all applicable
state license(s) for the product category(s) and areas for which the bidder is submitting a bid. Bidders will be disqualified if they
do not meet all state licensure requirements for the applicable product categories and for every state in a CBA. For bid
evaluation purposes, each location is not required to have licenses for every state in the CBA as long as each state has a
bidding location licensed for the product category. If there is a multi-state CBA, the bidder must collectively have all applicable
license(s) for every state in the CBA. Every location of the bidder is responsible for having all applicable license(s) for each
state in which it furnishes items/services.
I acknowledge and understand that I, as a bidder, have the applicable state licenses for every item in every product
category for each CBA for which I am bidding. This information must be on file in each location’s Medicare enrollment
record (i.e., Provider Enrollment, Chain and Ownership System (PECOS))  Yes

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

G. Business Information
Provide the number of years and months your organization has been in business.
Years

Months

in business

H. Type of Business
Select the business type that describes your organization. Bidders must submit certain financial documentation based
on the type of business identified in this response. Refer to the Request for Bid (RFB) instructions for a checklist of
required documents.
 Corporation (LLC, Professional Corporation, S Corp and C Corp)
 Sole Proprietorship
 Partnership

 Municipality and State Owned
 Non-Profit Organization

I. Service Delivery

How will your organization furnish items and services to Medicare beneficiaries? (Check all that apply.)

 Retail Location with Home Delivery

 Mail Order

 Home Delivery

J. Sanctions
Does your organization or any location(s) on your bid have any current or past legal actions, or sanctions such as
debarment within the past five (5) years?
 Yes  No
If yes, please refer to RFB instructions for additional information that you must submit.

K. CBA and Product Category
Identify below all of the CBA(s) and product category(s) combinations for which your organization is submitting a
bid(s).

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

Section 1a. Location-Specific Questions
Please provide the requested information for your primary location. This is the location (PTAN) that you used when
you registered for a User ID and password to access the DMEPOS Bidding System (DBidS).

A. Identifying Information

Provide the following information for the primary location:

Legal Business Name_____________________________________
DBA: __________________________________________________
Mailing Address Line 1
(Street Name and Number)

Mailing Address Line 2
(Suite, Room, etc.)

City/Town
Telephone Number
PTAN for this location

State

Zip

Toll Free Number (if available)
NPI Identification Number

Tax Identification Information Number (TIN)

B. Physical Address
Is the primary location’s mailing address the same as the physical address?  Yes  No
If the answer is No, please complete the following information.
Physical Address Line 1
(Street Name and Number)

Physical Address Line 2
(Suite, Room, etc.)

City/Town

State

Zip

C. CBA and Product Category
Identify the CBA/product category combination(s) that your primary location will be servicing. This location can only be
included in contract offers for the specific CBAs and product categories you identify here. You must select at least one
combination for the primary location.

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category
_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

Section 1b. Location-Specific Questions- Additional Locations
If you have additional locations you want to add to your bid, please complete the section below. You must include all
commonly-owned or commonly-controlled locations that are located in, or would furnish items to beneficiaries who
maintain a permanent residence in any of the CBAs included on your bid.

A. Identifying Information
Provide the following information for every additional location you want to include in your bid.
Legal Business Name

DBA:

Doing Business as Name (DBA)
Mailing Address Line 1
(Street Name and Number)

Mailing Address Line 2
(Suite, Room, etc.)

City/Town

State

Telephone Number

Toll Free Number (if available)

PTAN for this location

NPI Identification Number

Zip

Tax Identification Information Number (TIN)

B. Physical Address
Is the location’s mailing address the same as the physical address?  Yes  No
If the answer is No, please complete the following information.
Physical Address Line 1
(Street Name and Number)

Physical Address Line 2
(Suite, Room, etc.)

City/Town

State

Zip

C. CBA and Product Category
Identify the CBA/product category combination(s) that the location will be servicing. This location can only be included
in contract offers for the specific CBAs and product categories you identify here.

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category
_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
For CMS Use Only
Bidder No.

Date Application Received

Competitive Bidding Area (CBA)

Bidder’s Identifying Information
Supplier’s Legal Business Name

Primary Supplier’s Legal Business Name (if network)

FORM A: APPLICATION FOR NETWORKS
Please read all instructions completely. The primary network supplier must complete this

application in order to bid on behalf of a network.

Indicate how your business organization will be bidding (choose only one option).





Supplier with a Single Location (Complete Section 1-1a)
Supplier with Multiple Locations (Complete Section 1, 1a, & 1b)
Network (Complete Section 2-2a)

Section 2: Application for Networks
A. Business Organization Information
Do the Network Members have a signed legal contract that establishes the network?  Yes  No
Network Name_____________________________________________________

B. Specialty Supplier
Is your organization a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) that is bidding as a specialty supplier
that plans to furnish competitively bid items only to its own residents?
 Yes  No

C. Contact Person
Provide the name(s) of the person(s) who should be contacted to answer questions regarding the network
organization.
Contact Person(s): First Name
E-Mail Address

Last Name

Title

Telephone (include area code)

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

D. Authorized Official or Key Personnel

Provide the name(s) and title(s) of authorized officials or key personnel for the network.

Key Personnel: First Name

Last Name

Title

E. Accreditation
By the close of the bid window, all network locations must meet Medicare enrollment requirements, including being accredited
for all items in the product category(s) for which the supplier is submitting a bid. As required by 42 CFR § 414.414 (c), each
bidder must be enrolled, meet quality standards, and be accredited in order to be awarded a contract. Individual locations of a
supplier with multiple locations must separately meet these requirements to be included in a contract offer.
Identify the name(s) of the Medicare-approved organization(s) that has accredited the network members for the product
category(s) in which you are bidding.
Accrediting Organization

Accrediting Organization_____________________________________________

I acknowledge and understand that all members of the network must have a location or locations that is/are properly
accredited to furnish the specific item(s) and service(s) included in the bid. This information must be on file in the
organization’s enrollment record (i.e., Provider Enrollment, Chain and Ownership System (PECOS))  Yes

F. Licensure
By the close of the bid window, all network locations must meet Medicare enrollment requirements, including possessing all
applicable state license(s) for the product category(s) and areas for which the bidder is submitting a bid. Bidders will be
disqualified if they do not meet all state licensure requirements for the applicable product categories and for every state in a
CBA. For bid evaluation purposes, each location is not required to have licenses for every state in the CBA as long as each
state has a bidding location licensed for the product category. If there is a multi-state CBA, the bidder must collectively have all
applicable license(s) for every state in the CBA. Every location of the bidder is responsible for having all applicable license(s) for
each state in which it furnishes items/services.
I acknowledge and understand that I, as a bidder, have the applicable state licenses for every item in every product
category for each CBA for which I am bidding. This information must be on file in each location’s Medicare enrollment
record (i.e., Provider Enrollment, Chain and Ownership System (PECOS))  Yes

G. Business Information
Provide the number of years and months your primary network member has been in business.
Years
Months
in business

H. Type of Business
Select the business type that describes your network members’ business structure. Bidders must submit certain financial
documentation based on the type of business identified in this response. Refer to the Request for Bid (RFB) instructions for a
list of required documents and checklist.
 Corporation (LLC, Professional Corporation, S Corp and C Corp)
 Sole Proprietorship
 Partnership

 Municipality and State Owned
 Non-Profit Organization

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

I. Service Delivery

How will your network furnish items and services to Medicare beneficiaries? (Check all that apply.)

 Retail Location with Home Delivery
 Mail Order
 Home Delivery

J. Sanctions
Does your network or any location(s) on your bid have any current or past legal actions, or sanctions, such as
debarments within the past five (5) years?
 Yes  No
If yes, please refer to RFB instructions for additional information that you must submit.

K. CBA and Product Category

Identify below all of the CBA(s) and product category(s) for which your network is submitting a bid(s).

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category
Competitive Bidding Area (CBA)
Product Category

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

Section 2a. Location-Specific Questions
Please provide the requested information for your primary location. This is the location (PTAN) that you used when
you registered for a User ID and password to access the DMEPOS Bidding System (DBidS).

A. Identifying Information

Provide the following information for the primary network member.

Legal Business Name
Doing Business as Name (DBA)
Mailing Address Line 1
(Street Name and Number)

Mailing Address Line 2
(Suite, Room, etc.)

City/Town

State

Telephone Number

Toll Free Number (if available)

PTAN for this location

NPI Identification Number

Zip

Tax Identification Information Number (TIN)

B. Physical Address
Is the primary network member’s mailing address the same as the physical address?  Yes  No
If the answer is No, please complete the following information:
Physical Address Line 1
(Street Name and Number)

Physical Address Line 2
(Suite, Room, etc.)

City/Town

State

Zip

C. CBA and Product Category
Identify the CBA/product category combination(s) that your primary location will be servicing. You must select at least
one CBA and product category for the primary location. This location can only be included in contract offers for the
specific CBAs and product categories you identify here

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category
Competitive Bidding Area (CBA)
Product Category

_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)

Legal Business Name

Bidder Number

Section 2b. Location-Specific Questions-Additional Locations
If you have additional locations and network member locations, please complete the following questions. You must
include all commonly-owned or commonly-controlled locations that are located in (or would furnish items to
beneficiaries that maintain a permanent residence in) any of the CBAs in your bid.

A. Identifying Information

Provide the following information for each additional location you want to include in your bid.

Network Member Name
Legal Business Name
Doing Business as Name (DBA)
Mailing Address Line 1
(Street Name and Number)

Mailing Address Line 2
(Suite, Room, etc.)

City/Town

State

Telephone Number

Toll Free Number (if available)

PTAN for this location

NPI Identification Number

Zip

Tax Identification Information Number (TIN)

B. Physical Address
Is the location’s mailing address the same as the physical address?  Yes  No
If the answer is No, please complete the following information:
Physical Address Line 1
(Street Name and Number)

Physical Address Line 2
(Suite, Room, etc.)

City/Town

State

Zip

C. CBA and Product Category
Identify the CBA/product category combination(s) that the location will be servicing. This location can only be included
in contract offers for the specific CBAs and product category combinations you identify here.

Competitive Bidding Area (CBA)
Product Category

Competitive Bidding Area (CBA)
Product Category
Competitive Bidding Area (CBA)
Product Category
_________________________________________________________________________________________________________________________________________________

Form CMS-10169A (XX/XX) EFF (XX/XXXX)