Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)

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⚠️ Notice: This information collection may be referencing outdated material.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 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction
CMS-10169 Beneficiary Survey (English Language Version) 508_CMS-10169_Form D_ English.pdf Form and Instruction
CMS-10169 Beneficiary Survey (Spanish Language Version) 508_CMS-10169_Form_D_Spanish.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

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	Beneficiary Survey (English Language Version)	508_CMS-10169_Form D_ English.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10169	Beneficiary Survey (Spanish Language Version)	508_CMS-10169_Form_D_Spanish.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,667	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14,667	14,667
Annual IC Time Burden (Hours)	7,333	7,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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