Crosswalk - Form A

Current Placement	Title	Current Language	Revised Language	Revised Placement	Reason for Change
			FORM A
Section 1, A	Business Organization Information	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.	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 your type of business.	No change in the placement of this question	Changed the "c" in National chain to lower case and changed the "supplier's type of business" to "your type of business"
Section 1, 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? o Yes o No	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? o Yes o No	No change in the placement of this question	changed Skilled Nursing Facility and Nursing facility to lower case
Section1, F	Licensure	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	I acknowledge and understand that I, as a bidder, have the applicable state licenses for every item in every product category for each competitive bidding area (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	No change in the placement of this question	spelled out competitive bidding area (CBA)
Section 1b, K (this same change was made for Section 2 K (Networks)	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).	In accordance with §414.412(h), bidding suppliers must obtain a bid surety bond issued by an authorized surety on the Department of the Treasury’s Listing of Certified Companies for each CBA for which you are submitting a bid, by the bidding deadline . A copy of each bid surety bond must be received by the Competitive Bidding Implementation Contractor (CBIC) by the bidding deadline. You must review and acknowledge that you read and agree with the statement below. Check the box to accept. I acknowledge that I, as a bidder, have obtained a bid surety bond from an authorized surety for each CBA selected below. • Check the box in the right column for each CBA/product category combination for which your organization is submitting a bid(s). By checking the box, you are also attesting that you have obtained a bid surety bond for the CBA from an authorized surety. Later in the application, you will be required to identify the locations that will furnish the competitive bid item(s) and service(s) in the CBA(s).	No change in the placement of this question	Language was updated to include the statutory mandated bid surety bond language
Section 2			Application for Networks
Section 2,E	Accreditation	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	I acknowledge and understand that all members of the network must have a location(s) that is 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	No change in the placement of this question	a minor grammatical change was made.
Section 2,F	Licensure	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	I acknowledge and understand that I, as a bidder, have the applicable state licenses for every item in every product category for each competitive bidding area (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	No change in the placement of this question	spelled out competitive bidding area (CBA)
Section 2,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).	In accordance with §414.412(h), bidding suppliers must obtain a bid surety bond issued by an authorized surety on the Department of the Treasury’s Listing of Certified Companies for each CBA for which you are submitting a bid, by the bidding deadline. A copy of each bid surety bond must be received by the Competitive Bidding Implementation Contractor (CBIC) by the bidding deadline. You must review and acknowledge that you read and agree with the statement below. Check the box to accept. I acknowledge that I, as a bidder, have obtained a bid surety bond from an authorized surety for each CBA selected below. • Check the box in the right column for each CBA/product category combination for which your organization is submitting a bid(s). By checking the box, you are also attesting that you have obtained a bid surety bond for the CBA from an authorized surety. Later in the application, you will be required to identify the locations that will furnish the competitive bid item(s) and service(s) in the CBA(s).	No change in the placement of this question	Language was updated to include the statutory mandated bid surety bond language