Application for DMEPOS Competitve Bidding Program (Form A)

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⚠️ Notice: This information collection may be referencing outdated material.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 Application for DMEPOS Competitve Bidding Program (Form A) Form and Instruction
CMS-10169 Form A - Application for DMEPOS Competitive Bidding Prog 508_CMS-10169_Form_A.pdf Form and Instruction
508_DBidS Form A Screenshot 3.pdf Form A Screenshot 3 IC Document
508_DBidS Form A Screenshot 1.pdf Form A Screenshot 1 IC Document
508_DBidS Form A Screenshot 2.pdf Form A Screenshot 2 IC Document
508_DBidS Form A Screenshot 4.pdf Form A Screenshot 4 IC Document
508_DBidS Form A Screenshot 5.pdf Form A Screenshot 5 IC Document
508_DBidS Form A Screenshot 6.pdf Form A Screenshot 6 IC Document
508_DBidS Form A Screenshot 7.pdf Form A Screenshot 7 IC Document
508_DBidS Form A Screenshot 8.pdf Form A Screenshot 8 IC Document
508_DBidS Form A Screenshot 9.pdf Form A Screenshot 9 IC Document

Information Collection (IC) Details

IC Title:	Application for DMEPOS Competitve Bidding Program (Form A)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.410

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	Form A - Application for DMEPOS Competitive Bidding Program	508_CMS-10169_Form_A.pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,299	Number of Respondents for Small Entity: 909

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,299	1,299
Annual IC Time Burden (Hours)	10,389	10,389
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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