Information Collection

Bidding Form (Form B)

IC 212257 under ICR 201411-0938-001 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10169 Bidding Form (Form B)	Form and Instruction
CMS-10169 Form B _ Bidding Form 508_CMS-10169_Form_B.pdf	Form and Instruction
508_DBidS Form B Screenshot 1.pdf Form B Screenshot 1	IC Document
508_DBidS Form B Screenshot 2.pdf Form B Screenshot 2	IC Document
508_DBidS Form B Screenshot 3.pdf Form B Screenshot 3	IC Document
508_DBidS Form B Screenshot 4.pdf Form B Screenshot 4	IC Document

IC Title:

Bidding Form (Form B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.410

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10169	Form B _ Bidding Form	508_CMS-10169_Form_B.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: 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	17,944	17,944
Annual IC Time Burden (Hours)	215,324	215,324
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.